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HALL'S 

DIFFERENTIAL  DIAGNOSIS. 


Differential  Diagnosis  : 


A  MANUAL  OF  THE 


COMPARATIVE  SEMEIOLOGY 


OF    THE 


MORE  IMPORTANT  DISEASES. 


By  F.  de  HAVILLAND  HALL,  M.  D., 

ASSISTANT    PHYSICIAN    TO    THE    WESTMINSTER    HOSPITAL,    LONDON. 


SECOND  AMEKICAN  EDITION. 

EXTENSIVE    ADDITIONS. 


EDITED   BY  FRANK  WOODBURY,  M.  D. 

PHYSICIAN   TO   THE   GERMAN   HOSPITAL,   PHILADELPHIA. 


PHILADELPHIA: 

D.  G.  BRLNTON,  115  SOUTH  SEVENTH  ST. 
1881. 


Entered  according  to  Act  of  Congress,  in  the  year  1881,  by 

D.     G.     BRINTON, 

in  the  Office  of  the  Librarian  of  Congress,  in  "Washington,  D.  C. 

All  rights  reserved. 


n-ws\. 


Press  of  Wm.  F.  Fell  &  Co., 


1220-24  Sanson  Street, 
Philadelphia. 


CONTENTS. 


PAGE 

Introductory 12 


PART  I. 
GENERAL  DISEASES. 


CHAPTER  I. 


THE  FEVEES. 

The  Febrile  State 14 

Inflammatory,  or  Symptomatic  and  Essential  Fever 19 

The  Exanthematous  or  Eruptive  Fevers 21 

Typhoid  and  Typhus  Fevers 28 

Typhoid  and  Malarial  Fevers 34 

The  Typhoid  State 37 

Malarial  Fevers 38 

Cerebro- spinal  Fever 43 

Acute  Tubercular  Meningitis 48 

Yellow  Fever 49 

Relapsing  Fever 52 

CHAPTER  II. 

DISEASES  OF  THE  BLOOD. 

The  Dyscrasise 54 

The  Arthritic,  Dartrous,  or  Rheumic  Dyscrasia 54 

The  Scrofulous,  or  Strumous  Dyscrasia 56 

The  Syphilitic  Dyscrasia 58 

The  Tuberculous  Dyscrasia 59 

Rheumatism , 61 

Chronic  Rheumatism 62 

Gout 65 

Rheumatoid  Arthritis 66 

Pernicious  Anaemia  and  Leukaemia 66 

Remarks  on  the  Germ  Theory  and  Zymotic  Bowel  Affections 68 

v 


VI  CONTENTS. 

PART  II. 

LOCAL  DISEASES. 


CHAPTER  I. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

PAGE 

Nervous  Symptoms 73 

Cerebral  Congestion  and  Cerebral  Anaemia 75 

The  Symptoms  of  Cerebral  Apoplexy  Contrasted  with  those   of  Drunkenness, 

Narcotic  Poisoning,  Urasmia,  Hysteria,  Syncope  and  Asphyxia 75 

Cerebral  Hemorrhage  rs.  Thrombosis  and  Embolism 77 

Acute  Cerebral  Inflammations 78 

The  Ophthalmoscope  in  Nervous  Disorders 80 

Headache 82 

Chronic  Cerebral  Disorders 84 

Hypertrophy  of  Brain  and  Hydrocephalus 84 

Brain  Tumors,  Softening,  Abscess,  Meningitis  and  Thrombosis 85 

Cerebral  Sclerosis  vs.  Defective  Development  of  Intelligence 85 

Localization  of  Brain  Disease 86 

Lesions  of  Cerebral  Cortex  (with  Diagram) 86 

Disease  of  Brain  Centres  other  than  Cortical 88 

Tabular  View  of  Paralysis 89 

Spinal  Diseases 91 

Location  of  Spinal  Lesions 93 

Tabular  View  of  Spinal  Paralysis 93 

Myelitis,  Meningitis  and  Congestion  Compared 96 

Chronic  Spinal  Disorders 97 

Degenerative  Diseases 98 

Sclerosis  of  Cord 99 

Tendon-reflex  Symptom  of  Westphal 1 03 

Cerebro-spinal  Sclerosis,  Paralysis  Agitans  and  Locomotor-ataxia 104 

Paraplegia,  from  Reflex  Irritation  and  Myelitis 105 

Pseudo-hypertrophic  Paralysis 107 

Paralysis,  from  Lead  Poisoning  and  Hysteria 109 

General  Paralysis  of  the  Insane 109 

General  Paralysis  and  Locomotor-ataxia 112 

General  Paralysis  and  Syphilitic  Paralysis 113 

Spinal  Irritation  and  Spinal  Weakness 114 

Hysteria 115 

Epilepsy  and  Hystero- epilepsy 116 

Neuralgia .' 117 

Neuralgia  and  Myalgia 118 


CONTENTS.  VII 

/ 

PAGE 

Cerebral  Abscess  vs.  Cerebral  Neuralgia 119 

Insanity 120 

Mania  and  Melancholia 122 

CHAPTER  II. 

DISEASES  OF  THE  RESPIRATORY  APPARATUS. 

Symptoms  of  Laryngeal  Diseases 125 

Diagnostic  Table  of  Acute  Laryngitis;  Chronic  Laryngitis;  Syphilitic  Laryngitis  ; 

Tubercular  Laryngitis 120 

Perichondritis  ;  Benign  Growths  ;  Malignant  Growths  ;  Neuroses  of  the  Larynx  ...  128 

Croup  and  Diphtheria 130 

Spasmodic  Croup 130 

Inflammatory  Croup 130 

Membranous  Croup 131 

Diphtheria 131 

Tonsillitis,  Catarrhal  and  Parenchymatous 132 

The  Regions  of  the  Chest 133 

Normal  Differences  between  the  two  Sides  of  the  Chest 134 

Methods  of  Physical  Examination 135 

Normal  Respiratory  Sounds 136 

Normal  Voice  Sounds 136 

Abnormal  Percussion  Sounds 137 

Abnormal  Respiratory  Sounds 138 

Amphoric  Sound 140 

Abnormal  Voice  Sounds 141 

General  Rules  for  Diagnosis 142 

The  Forms  of  Phthisis  (Catarrhal,  Fibroid,  Tubercular) 143 

The  Diagnosis  of  Incipient  Phthisis 145 

Diagnosis  between  Incipient  Phthisis  and  Bronchitis 148 

Clinical  History  of  Phthisis 149 

Acute  Phthisis  (Acute  Miliary  Tuberculosis) 150 

Syphilitic  Phthisis 152 

Bronchitis,  Acute  and  Chronic 152 

Capillary  Bronchitis  compared  with  Pneumonia 155 

Pneumonia  and  Pleurisy 156 

Pleurisy  and  Hydrothorax 157 

Pleurisy  with  Effusion  and  Pneumonia  with  Consolidation  Compared 160 

Diagnosis  between  Pneumonia  and  Pulmonary  Apoplexy 161 

Pulmonary  Thrombosis 161 

Asthma , 162 

Pneumothorax  and  Pneumo-hydrothorax 163 

Emphysema,  Vesicular  and  Interlobular 164 

Cancer  of  the  Lung 165 


VI  ll  CONTENTS. 

CHAPTER  III. 

DISEASES  OF  THE  CIRCULATORY  APPARATUS. 

PAOl 

The  Precordial  Regions K>7 

The  Ana  of  Cardiac  Dullness 1C.8 

Normal  Sounds  and  Impulse  of  Heart L69 

Endocardial  Marmora 170 

Genera]  Rules  for  the  Diagnosis  of  Heart  Disease 170 

Constitutional  Symptoms  of  Heart  Disease 171 

Clulil ling  of  the  Fingers 172 

Differential  Signs  between  Anemic  and  Organic  Blood  Murmurs 173 

Pain  at  and  near  the  Heart 173 

Aphorisms  Regarding  Angina  Pectoris 174 

Differential  Signs  of  Aortic  Obstruction  and  Aortic  Incompetency 175 

Differential  Signs  between  Mitral  Obstruction  and  Mitral  Incompetency 176 

Differential  Signs  between  Pulmonary  Obstruction  and  Tricuspid  Regurgitation...  178 

Pericarditis 178 

Diagnosis  between  Acute  Endocardial  and  Exocardial  Sounds 180 

Differential  Signs  of  Cardiac  Dilatation  and  Pericarditis  with  Effusion 180 

Differential  Signs  of  Simple  Hypertrophy,   Hypertrophy    with  Dilatation,   and 

Simple  Dilatation 181 

Fatty  Degeneration  of  the  Heart 181 

Slow  Heart 183 

CHAPTER  IV. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Principal  Symptoms 184 

The  Tongue 184 

The  Appetite 185 

Acidity  (1)  from  Fermentation;  (2)  from  Hyper-Secretion 186 

Pain 187 

Flatulence  and  Eructation * 188 

Vertigo,  (1)  Stomachal;  (2)  Cerebral 188 

Vomiting,  (1)  Stomachal;   (2)  Cerebral 189 

Comparison  of  Atonic  Dyspepsia,  Chronic  Gastritis,  Gastric  Ulcer  and  Gastric 

Cancer 191 

Indigestion  and  Dyspepsia 195 

Abdominal  Phthisis 195 

Obstruction  of  the  Bowels,  Enteritis  and  Colitis 196 

Method  of  Examination  of  the  Liver 198 

Significance  of  Pain  in  the  Liver 199 

Significance  of  Jaundice 200 

Jaundice  with  Obstruction 201 

Jaundice  without  Obstruction. 201 


CONTENTS.  IX 

PAOE 

Diseases  Characterized  by  Enlargement  with  Smooth  Surface 202 

Enlargement  with  Uneven  Surface 20:; 

With  Diminution  of  the  Organ 20-'i 

Hepatic  Abscess 204 

Internal  Parasites 205 

Tape-worm , 205 

Hydatids 206 

Round  Worms 206 

Thread  Worms 200 

Trichinosis , 206 

CHAPTER  V. 

DISEASES  OF  THE  UKINAKT  SYSTEM. 

The  Early  Signs  of  Bright's  Disease 208 

Comparative  Diagnosis  of  the  Different  Forms  of  Bright's  Disease  (Acute  Paren- 
chymatous Nephritis,  Chronic  Tubal  Nephritis,  Yellow  Fatty  Kidney, 
Secondary  Contraction  of  Kidney,  Interstitial  Nephritis  or  Renal  Cirrhosis, 
Albuminoid  or  Amyloid  Renal  Degeneration,  Parenchymatous  Renal  De- 
generation)   210 

Diabetes  Mellitus  and  Glycosuria 212 

Diabetes  Insipidus  and  Hydruria 215 

Bile  in  the  Urine 215 

Urinary  Calculi 216 


PUBLISHER'S  NOTE 


SECOND    AMERICAN    EDITION 


The  present  work  is  founded  upon  Dr.  F.  De  Havilland  Hall's 

Synopsis  of  the  Diseases  of  the  Larynx,  Lungs,  and  Heart.  The  plan 
adopted  by  De.  Hall  has,  however,  been  extended  to  embrace  all  the 
more  frequent  and  important  diseases. 

In  the  preface  to  the  first  American  edition  the  editor  stated  that  he 
had  held  especially  in  view  (1)  the  early  and  often  overlooked  signs 
of  the  presence  of  disease ;  (2)  the  collection  of  whatever  symptoms  are 
alleged  on  good  authority  to  be  pathognomonic  of  pathological  conditions; 
(3)  any  peculiar  features  which  diseases  have  been  found  to  present  in 
this  country.  "  Preference  has  been  given  to  American  over  European 
authorities,  as  every  year  adds  confirmation  to  the  opinion,  now  widely 
received,  that  diseased  conditions  assume  very  different  aspects  under  dif- 
ferent climatic  and  sociological  surroundings." 

As  the  editor  of  the  first  edition  could  not  revise  the  present  one,  the 
publisher  was  fortunate  enough  to  complete  an  arrangement  with  De. 
Feank  Woodbuey  to  give  it  a  thorough  revision,  and  to  add  to  it 
what  was  lacking  to  make  it  a  complete  work  within  the  limits  which  it 
aims  to  cover. 


XI 


INTRODUCTORY. 


The  nomenclature  of  diseases  adopted  by  the  best  authorities  divide 
them  into  two  great  classes — General  Diseases  and  Local  Diseases. 
General  diseases  may  be  said  to  comprehend  those  which  pervade  the 
whole  system,  and  in  which  any  local  affection  may  be  regarded  as  acci- 
dental ;  while  local  diseases  are  those  which  particularly  affect  certain 
organs,  and  in  which  the  involvement  of  any  other  part  of  the  body  is 
but  a  sequel  of  the  primary  lesion. 

This  classification,  having  much  to  recommend  it,  from  a  clinical  stand- 
point, is  the  one  most  practically  useful  to  the  physician.  The  first 
question  he  should  put  to  himself  on  examining  a  patient  is,  Have  we  here 
a  general  or  a  local  disease  ?  He  reaches  the  answer  by  excluding  those 
organs  whose  form  and  functions  present  nothing  abnormal,  and  by 
distinguishing  among  such  as  are  implicated  those  which  indicate  primary 
and  essential  lesions,  from  those  which  are  affected  accidentally  or  second- 
arily. Where  no  primary  lesions  are  discoverable,  he  may  conclude  that 
he  has  to  do  with  a  general  disease. 

For  the  purpose  of  diagnosis,  General  Diseases  are  best  divided  into 
the  two  classes  of  (1)  Fevers  and  (2)  Diseases  of  the  Blood.  These  also 
are  each  divisible  into  two  or  more  classes  marked  by  one  or  two  leading 
and  prominent  symptoms,  which  are  the  guides  to  the  diagnostician.  Thus, 

The  Essential  Fevers  are  usually  acute  in  their  course,  and  either 
characterized  by  an  eruption  of  a  well-defined  character  (the  Exanthe- 
mata) ;  or  by  a  recurrent  marked  diminution  (remission)  or  total  cessation 
(intermission)  of  the  symptoms  (Periodic  fevers) ;  or  else  by  a  persistent 
course  not  manifesting  either  of  these  phenomena  (Continued  fever). 

Blood   Changes  are  rarely  acute,  and  are  either  constitutional   (the 

xiii 


XIV  INTRODUCTORY. 

Dvs.rasi.e);  or  else  characterized  by  definite  organic  lesions  (Rheumatism, 

Gout);  or  by  a  physical  and  generally  recognizable  change  in  the  blood 
itself  (Anaemia,  Leuksemia,  Scurvy  and  Purpura). 

Local  Diseases  are  more  conveniently  classified  with  reference  to  the 
physiological  than  the  anatomical  divisions  of  the  body.  The  functions 
of  life  are  carried  on  by  the  Nervous,  Respiratory, Circulatory, Digestive 
and  Urinary  systems ;  and  the  impairments  of  each  of  these  form  classes 
of  diseases  which  are  broadly  discriminated  by  signs  easy  of  recognition. 
The  niceties  of  diagnosis  are  needed  rather  to  distinguish  between  the 
varied  diseases  peculiar  to  each  of  these  systems  than  to  locate  the 
disturbance  in  one  or  the  other  of  them. 


PART  I. 

G-ENEBAL  DISEASES. 


CHAPTER  I. 

THE  FEVERS. 

Contents. — The  Febrile  State — Inflammatory,  or  Symptomatic,  and 
Essential  Fevers — The  Exanthematous  or  Eruptive  Fevers — Typhoid 
and  Typhus  Fevers — Typhoid  and  Malarial  Fevers — The  Typhoid 
State — Malarial  Fevers — Cerebrospinal  Meningitis — Acute  Tubercular 
Meningitis — Yellow  Fever — Relapsing  Fever. 

THE  FEBRILE  STATE. 

The  most  common  of  all  forms  of  disease  is  that  which  is  presented 
by  the  Febrile  State.  The  chief  objective  symptoms  which  it  offers  are 
found  in 

I.  The  temperature. 
II.  The  pulse. 
III.  The  tongue  and  uvula. 
IY.  The  urine. 
V.  The  state  of  the  skin. 

I.  The  temperature  is  one  of  the  most  prominent  of  the  phenomena 
in  fever,  and  by  many  is  regarded  as  the  essential  feature  of  the  febrile 
condition;  yet  its  correct  appreciation  was  never  understood  previous  to 
the  labors  of  Wundeklich.  Now,  the  clinical  thermometer  is  considered 
as  indispensable  to  the  practitioner,  as  the  lancet  used  to  be. 

In  using  the  clinical  thermometer,  Dr.  Sydney  Ringer,  of  London, 
lays  down  the  rule  that  in  order  to  insure  correctness  in  the  observations, 
the  following  conditions  must  be  fulfilled : — 

1st.  That  the  patient  should  be  in  bed,  otherwise  the  temperature  of 
the  surface  will  be  much  below  that  of  the  internal  organs. 

1-5 


16  DIFFERENTIAL    DIAGNOSIS. 

2d.  That  the  patient  be  in  bed  at  least  one  hour  before  the  observations 
are  made,  since  that  time  is  necessary  for  the  surface  of  the  body  to  regain 
tlic  heal  ln.-t  by  previous  exposure. 

3d.  The  position  of  the  person  examined  should  be  such  that  the 
anterior  and  posterior  edges  of  the  axilla  are  relaxed,  for  otherwise  a 
cup-shaped  cavity  is  formed,  in  which  the  thermometer  moves  freely* 
without  being  in  contact  with  its  walls.  This  occurs  especially  in 
emaciated  persons. 

4th.  The  temperature  should  be  taken  twice  daily,  say  at  eight  in  the 
morning  and  eight  in  the  evening.  If  but  one  observation  is  possible, 
then  the  evening  should  be  preferred,  since  the  morning  temperature, 
abnormal  though  it  may  be,  rises  in  the  evening. 

5th.  The  thermometer  should  remain  in  the  axilla  at  least  five  minutes. 

As  regards  the  peripheral  parts,  such  as  the  hands  and  feet,  accord- 
to  Dr.  H.  Wegscheider,*  the  following  propositions  should  be  received 
in  reference  to  the  distribution  of  temperature  in  febrile  diseases: — 

1st.  There  is  no  constant  relation  between  the  internal  temperature,  as 
measured  in  the  axilla,  and  the  general  temperature  of  the  surface. 

2d.  Two  completely  symmetrical  parts  of  the  skin,  as  between  the  toes, 
show  no  proportionate  course  in  their  temperature ;  not  only  do  they 
differ  by  not  rising  or  falling  to  the  same  level,  but  one  may  rise  while 
the  other  remains  stationary  or  falls,  or  vice  versd. 

3d.  There  is  greater  variation  in  the  temperature  curves  in  the  same 
part  of  the  skin  in  the  same  person  in  fever  than  in  health ;  but  in  fever 
there  is  a  striking  fall  of  temperature,  notably  lower  than  in  the  healthy 
state.  However,  in  those  people  who  suffer  from  cold  feet  the  tempera- 
ture is  often  as  low,  or  somewhat  lower. 

4th.  It  follows,  from  the  last,  that  there  is  a  greater  difference,  in  fever, 
between  the  temperature  of  the  axilla  and  that  of  the  periphery  than  any 
changes  of  local  temperature  which  may  occur  in  health. 

Although  the  axilla  is  generally  selected,  on  account  of  convenience, 
the  temperature  is  often  taken  with  the  thermometer  in  the  mouth,  rectum 
or  vagina,  and  it  is  believed  that  such  observations  give  more  correct 
indications  of  the  heat  of  the  body  than  those  taken  on  the  surface. 

The  temperature  fluctuations  in  the  various  zymotic  diseases  have  now 
*  Archiv.  filr  Pathologie,  Feb.  1877. 


FEVERS. 


17 


been  carefully  studied  by  many  clinical  observers,  who  have  deduced 
observations  which  are  of  great  service  in  diagnosis,  as  some  of  them 
are  characteristic. 

A  pretty  constant  increase  and  decrease  of  temperature  exists  in  the 
several  specific  fevers,  a  close  observation  of  which,  in  accordance  with 
the  foregoing  rules,  will  often  serve  as  a  valuable  aid  both  in  diagnosis 
and  in  prognosis.  Dr.  Wunderlich,  in  his  work,  gives  useful  tables 
for  this  purpose,  and  we  subjoin  a  valuable  comparative  table  of  the  pulse 
as  well  as  the  temperature  in  seven  of  the  more  frequent  febrile  diseases, 
drawn  from  recent  English  observations. 

COMPARATIVE   TABLE    OF  THE   TEMPERATURE  AND  PULSE   IN  THE 
LEADING  FEBRILE  DISEASES. 


Day. 

Typhus 
Fever. 

Typhoid 
Fever. 

T. 

P. 

108 

113 

114 

122 

124 

122 

113 

117 

119 

108 

106 

100 

98 

92 

90 

85 

T. 

102. 

103.1 

103.4 

102.7 

103.2 

103.7 

102.5 

103. 

102.6 

103. 

102.5 

102.2 

102.4 

101.8 

102. 

101.4 

98.8 
101.4 
102.2 

98.8 

P. 

98 

98 
110 
107 
104 
107 
108 
108 
111 
111 
112 
108 
109 
107 
100 
100 

98 
105 
100 

98 

1st 

104.8 

103.6 

103. 

103.2 

104.2 

103.8 

103. 

102.7 

102.4 

102.2 

100.5 

100. 

99.4 

98.7 

98.4 

98.2 

2d 

3d 

4th 

5th 

6th 

7th 

8th 

9th 

10th 

11th 

12th 

13th 

14th 

15th 

16th 

17th 

18th 

19th 

20th 

21st 

Measles. 


102.3 

103 

100.2 

98. 

98. 


130 
124 
112 
102 
98 
80 


Scarlet 
Fever. 


104.2 

104. 

103. 

101.2 

100.6 

100. 

100. 

99.8 

99. 

98.6 


144 
148 
134 
122 
108' 
106! 
110 
108 
100 
104 
84 


Febricula. 


103. 
103.7 
104 
102.6 
98.4 


99 


Kheumatic  . 
Fever.       (Pneumonia. 


99 
103 
105  101.8 

99  102. 
102. 


103. 
100. 
100. 

99.4 
101. 
101. 
102. 
100.9 
100. 

98. 

99. 
102. 
103. 
101.6 
101.7 


105 

114 


102. 
102. 
103. 
104. 
103. 


116  1102.8 


120 

90| 

96 

86 

104 

102 

100 

100 

88 

90 

94 

96 

102 

100 

104 


100. 
99. 
98. 


8  123 

3  120 

6  122 

126 

122 

122 

114 

94 

78 


The  above  table,  prepared  from  a  series  of  observations,  by  Dr.  J.  S. 
"Warter,*  illustrates  the  normal  and  average  contrasts  of  pulse  and 
temperature  in  the  course  of  the  diseases  specified,  when  their  tendency  is 
to  recovery. 

*  St.  Bartliolomeio'  s  Hospital  Reports,  vol.  ii,  p.  78. 


18  DIFFERENTIAL   DIAGNOSIS. 

II.  The  pulse  is  increased  in  frequency,  and  may  be  either  hard,  full 
and  bounding,  or  tense,  small  and  contracted.  The  former  condition  is 
more  common  in  active  inflammation  of  the  organs  above  the  diaphragm ; 
the  latter,  in  many  inflammations  below  the  diaphragm  and  in  idiopathic 
fevers.  In  fevers  of  a  typhoid  form,  an  unusually  slow  pulse  is  some- 
times encountered,  as  also  a  pulse  with  apparently  a  double  beat,  the 
"dicrotic"  pulse.  In  the  later  stages  the  pulse  may  be  soft,  gaseous  or 
thready,  indicating  febrile  changes  in  the  walls  of  the  vessels  and  the 
heart. 

III.  The  tongue  in  the  beginning  of  the  febrile  state  is  usually  whiter 
and  dryer  than  usual,  and  more  or  less  coated  with  a  "fur"  or  viscid 
covering,  from  the  more  rapid  evaporation  of  the  watery  secretions. 
Later  on,  in  the  progress  of  severe  fever,  the  tongue  becomes  dry,  and 
the  exsiccated  mucus  and  epithelium  form  a  brownish  or  blackish  crust, 
while  the  papilla?  shrink,  so  that  on  this  crust  becoming  detached,  the 
surface  of  the  organ  looks  glazed  and  smooth.  The  peculiar  appearance 
of  the  tongue  in  certain  diseases  will  be  described  in  connection  with 
these  diseases. 

IV.  The  urine  in  fever  is  scanty  and  high  colored.  Its  alteration  from 
the  healthy  average  is  chiefly  in  the  much  larger  quantity  of  urea  and 
urates  which  it  contains,  and  the  diminution  of  its  chlorides.  According 
to  the  researches  of  Dr.  J.  Burdon  Sanderson,  in  the  early  stage  of 
fever  a  patient  excretes  about  three  times  as  much  urea  as  he  would  do 
on  the  same  diet  if  he  were  in  health,  the  difference  between  the  healthy 
and  the  fevered  body  consisting  chiefly  in  this,  that  whereas  the  former 
discharges  a  quantity  of  nitrogen  equal  to  that  taken  in,  the  latter  wastes 
the  store  of  nitrogen  contained  in  its  own  tissues.  That  this  disorder  of 
nutrition  is  an  essential  constituent  of  the  febrile  process  is  indicated  by 
the  fact  that  it  not  only  accompanies  the  other  phenomena  of  fever  during 
their  whole  course,  but  precedes  the  earliest  symptoms  and  follows  the 
latest.  That  it  anticipates  the  beginning  of  fever  was  first  demonstrated 
by  Dr.  Sidney  Ringer  in  his  investigation  of  the  relation  between 
temperature  and  the  discharge  of  urea,  in  ague.  That  the  same  condition 
continues  after  the  crisis  has  passed,  i.e.,  the  temperature  has  begun  to 
sink,  was  shown  by  Dr.  Squarey. 

There  are  various  methods  of  determining  the  rate  of  secretion  and 


FEVERS.  1 9 

the  amount  of  urea.  Its  relative  excess  may  be  inferred  when  the  urine 
has  a  deep  yellow  color,  a  high  specific  gravity,  and  a  strong  urinous 
odor.  If  a  small  quantity  of  it  be  allowed  to  evaporate  to  a  mucila- 
ginous consistence,  and  nitric  acid  be  added,  drop  by  drop,  crystals  of 
nitrate  of  urea  are  found  after  a  few  hours.  They  are  of  a  pearly  white 
lustre,  and  their  proportion  roughly  indicates  the  quantity  present. 
When  the  urea  is  in  great  excess,  the  crystals  will  form  on  the  addition  of 
nitric  acid  to  the  urine,  without  the  preliminary  evaporation,  by  merely 
allowing  the  test  tube  to  stand  for  a  short  time. 

V.  The  skin,  in  common  with  the  other  emunctories,  has  its  functions 
much  influenced  by  the  fever  process.  Apart  from  the  changes  in  tem- 
perature, considered  above,  there  are  alterations  in  the  appearance  of  the 
skin,  and  in  the  character  of  its  secretions,  which  accompany  fevers ; 
certain  eruptions  also  appear,  that  are  more  or  less  characteristic ;  such  as 
the  smallpox  pustule,  the  chicken-pox  vesicle,  the  urticarial  wheal,  and 
the  scarlatinal  acute  desquamative  dermatitis.  The  parasitic  diseases  of 
the  skin,  although  they  may  accidentally  be  associated  with  pyrexia, 
exist  entirely  independently,  and  the  fever  bears  no  causal  relationship  to 
them. 

The  skin  during  fever  has  for  its  typical  appearance  a  color  which  if 
not  decidedly  dull  and  sallow,  is  at  least  less  clear  than  in  health  ;  in 
typhus  it  may  be  quite  dusky ;  in  bilious  remittent  and  yellow  fever  it 
becomes  jaundiced.  In  typhoid  the  surface  is  more  nearly  that  of  health, 
but  the  cheeks  are  flushed  and  there  are  rose-spots  on  the  chest  and 
abdomen.  In  acute  rheumatism  and  in  the  third  stage  of  intermittent, 
the  skin  is  covered  by  a  profuse  perspiration,  which  in  the  former  case 
has  a  sour  smell.  Exhausting  sweats  also  occur  in  pyaemia  and  phthisis. 
But  the  dull-colored,  dry  and  harsh  skin  is  the  characteristic  appearance, 
and  is  due  to  deficient  action  of  the  perspiratory  and  other  glands. 

INFLAMMATORY  (SYMPTOMATIC)  AND  ESSENTIAL 

FEVERS. 

The  group  of  symptoms,  collectively  known  as  a  fever,  often  accompa- 
nies strictly  local  maladies  and  injuries.  In  such  cases  it  is  distinguished 
as  Inflammatory,  or  Symptomatic,  Fever,  and  it  is  of  the  first  importance 
to  distinguish  it  from  Essential,  or  Idiopathic,  Fever,  under  which  general 


20 


DIFFERENTIAL   DIAGNOSIS. 


term  all  true  fevers  are  included.  The  development  of  this  distinction 
has  been  one  of  the  most  prominent  achievements  of  the  modern  methods 
of  diagnosis.  "  It  is  astonishing,"  remarks  a  recent  writer,  "with  the 
progress  of  medicine,  how  many  affections  have  been  passed  over  from 
the  domain  of  fevers  to  the  narrower  circle  of  inflammation  of  individual 
organs."  Hence  it  is  of  prime  importance  to  determine  promptly  in  the 
beginning  of  a  case  whether  the  febrile  symptoms  are  a  feature  of  a  local 
disease  or  the  commencement  of  a  general  one. 


Inflammatory  or  Symptomatic  Fever. 

Is  usually  preceded  by  some  local 
lesions  or  symptoms. 

Pulse  frequent,  full  and  generally 
tense. 

Is  accompanied  by  marked  and 
definite  local  disturbance. 

Course   is    indefinite,  dependent 
upon  the  progress  of  the  local  lesion. 

Anatomical    lesions   definite  and 
invariable. 

Prognosis   mainly  depends  upon 
the  progress  of  local  lesion. 


Essential  or  Idiopathic  Fever. 

Has  no  definite  antecedent  local 
symptoms. 

Pulse  frequent,  full  or  small,  but 
rarely  tense.     (  Da  Costa.  ) 

Local  disturbances  vary,  and  are 
not  prominent,  or  but  temporarily  so. 

Runs  a  definite  course,  with  a 
strong  tendency  to  spontaneous  ter- 
mination at  a  given  time. 

Generally  characterized  by  rela- 
tively unimportant,  or  entirely  ab- 
sent anatomical  lesions. 

Local  manifestations  of  less  im- 
portance in  estimating  the  prognosis. 


Dr.  William  Stokes*  divides  the  local  symptoms  of  essential  fever 
into  three  groups :  (1)  Functional  or  nervous;  (2)  those  dependent  on 
special  anatomical  changes;  (3)  those  arising  from  re-active  inflammation. 

Examples  of  functional  symptoms  are  delirium,  carphologia,  cough, 
diarrhoea,  epigastric  tenderness,  and  the  like ;  of  the  second  group,  the 
alterations  which  occur  in  the  brain,  heart,  lungs,  spleen  or  intestinal 
glands;  and  of  the  third,  the  swelling  and  infiltration  of  organs.  What 
he  calls  "  the  grand  rule  of  diagnosis"  in  fever  is  not  to  apply  to  these  local 
symptoms  in  essential  fever  the  rules  of  diagnosis  of  local  diseases,  as  this 
would  lead  to  a  false  appreciation  of  the  disease,  and  to  erroneous  treat- 
ment. For  example,  a  typhus  patient  may  exhibit  the  marked  symptoms 
*  "Lectures  on  Fever,"  London,  1874. 


FEVERS.  21 

of  inflammation  of  the  brain;  but  if  he  is  treated  with  active  antiphlo- 
gistic treatment,  and  with  ice  to  the  head;  and  leeches,  he  forthwith  sinks 
and  dies. 

Of  hardly  less  importance  is  the  distinction  between  organic  and 
functional  (or  neurotic)  changes  in  fevers.  Delirium,  pain,  coma,  convul- 
sions, cough,  etc.,  may  all  appear  as  phenomena  of  the  evolution  of  the 
poison  which  produces  a  general  fever,  without  signifying  any  definite 
anatomical  lesion.  In  other  words,  essential  feveV  produces  local  symp- 
toms without  organic  change.  "It  is/'  remarks  the  author  just  quoted, 
"  because  this  proposition  has  not  been  sufficiently  accepted,  sufficiently 
engraved  upon  the  minds  of  medical  men,  that  so  much  mischief  has 
been  done  in  the  erroneous  treatment  of  fever." 

THE    DIAGNOSIS    OF    THE    ESSENTIAL   OR  ERUPTIVE 
FEVERS  (EXANTHEMATA). 

This  group  includes  smallpox,  varioloid,  scarlet  fever,  measles,  roseola, 
and  also  those  more  indefinite  forms,  varicella  and  rotheln.  They  have 
many  points  of  similarity.  "  They  are  all  characterized  by  a  period  of 
incubation,  during  which  the  poison  lies  dormant  in  the  system ;  by  a 
fever  of  more  or  less  intensity  preceding  the  eruption ;  by  an  eruption 
which  presents  a  distinct  aspect  in  each  disease,  and  which  pursues  a 
definite,  clearly  defined  course  until  it,  and  with  it  the  febrile  malady, 
disappears.  Moreover,  they  are  all  very  prone  to  occasion  serious 
sequela? ;  are  all,  in  the  main,  disorders  of  childhood ;  rarely  attack  the 
same  person  twice;  are  contagious,  and  have  not  as  yet  been  brought 
under  specific  treatment."     (Da  Costa.) 

It  is  of  great  credit  to  the  practitioner,  and  often  of  the  utmost  utility 
to  others,  for  him  to  make  an  early  diagnosis  between  these  diseases. 
This  is  not  always  possible  to  accomplish.  But  a  close  observer  will  find 
several  indications  which  will  guide  him  to  a  correct  opinion  before  the 
appearance  of  the  rash.     One  of  the  principal  of  these  is 

The  condition  of  the  throat.  This  region  is  affected  at  a  very  early 
stage  in  nearly  all  cases.  In  simple  scarlatina  the  very  earliest  symptom 
is  a  more  or  less  uniform  redness  of  the  middle  of  the  soft  palate,  the 
uvula  alone,  or  the  uvula,  anterior  pillars  of  the  fauces,  and  tonsils ; 
never  the  posterior  wall  of  the  pharynx  alone.     On  the  other  hand,  in 


22  DIFFERENTIAL   DIAGNOSIS. 

smallpox,  the  part  first  affected  is  the  posterior  wall  of  the  pharynx ; 
while  in  measles  the  posterior  walls  of  the  fauces  and  neighboring  parts 
of  the  pharynx  are  always  redder  than  the  anterior  pillars  and  soft 
palate  (Dr.  Alois  Monti).  In  rotheln  and  measles  the  tonsils  are  red 
and  swollen  early  in  the  disease ;  but  in  simple  scarlet  fever,  for  the  first 
twelve  hours  there  is  generally  very  little  swelling  of  the  affected  parts, 
and  children  seldom  complain  of  pain  in  the  neck  or  in  swallowing. 
After  twelve  or  twenty-four  hours  the  swelling  commences,  and  the 
redness  becomes  less  uniform,  and  more  punctiform.  This  peculiar 
punctiform  appearance  may  be  noted  often  ten  or  twelve  hours  before 
the  rash  on  the  skin  is  visible. 

If  in  malignant  scarlatinal  sore  throat,  however,  there  is,  from  the  first, 
parenchymatous  inflammation  of  the  tonsils  and  the  submucous  con- 
nective tissue,  and  this  condition  is  associated  with  well-marked  nervous 
symptoms,  a  severe  case  with  ulceration  of  the  fauces  may  be  confidently 
predicted. 

Iu  general  terms,  it  may  be  said  that  when  the  soft  palate  has  a  diffused 
red  hue,  "similar,"  as  Trousseau  remarks,  "to,  but  deeper  than,  that  of 
the  skin,"  while  the  tonsils  are  not  involved ;  when  with  this  is  a  very 
hot  skin,  a  very  quick  pulse,  vomiting,  a  tongue  with  thick,  creamy  fur, 
red  borders,  and  prominent  papula? ;  and  with  these  symptoms,  exposure 
to  the  presence  of  a  scarlatinal  epidemic,  the  physician  need  not  hesitate 
in  pronouncing  it  scarlet  fever. 

A  very  early  symptom  of  scarlet  fever  has  been  insisted  upon  as  strictly 
pathognomonic  by  an  Irish  physician,  Dr.  Joseph  Duggan.*  It  is  that 
the  eye  assumes  a  peculiar  brilliant  and  glistening  stare,  very  different 
from  the  liquid,  tender,  watery  eye  of  measles,  and  which,  once  carefully 
noted,  remains  impressed  on  the  observer's  memory. 

The  character  of  the  preliminary  fever  often  differs.  In  scarlatina  it 
is  marked  and  high,  which  distinguishes  it  broadly  from  diphtheria, 
which  is  not  marked  at  the  outset;  in  measles  it  is  of  a  catarrhal  form  ; 
while  in  smallpox  it  is  often  associated  with  very  severe  pains  in  the  back 
and  loins,  not  observed  in  the  other  exanthemata.  This  spine-ache  is 
central  in  its  position,  and  is  less  affected  by  change  of  posture  than  is  the 
pain  of  lumbago,  and  is  not  confined  to  one  side  nor  to  the  erector 
*  Medical  Press  and  Circular,  Feb.,  18G9. 


FEVERS.  2.; 

spince  muscles.  It  is  stated  by  some  authors  that  this  pain  is  increased  in 
proportion  with  the  severity  of  the  attack,  and  thus  forms  an  important 
element  in  the  prognosis ;  but  this  statement  should  be  confined  in  its 
application  to  adults,  as  in  children  the  rachialgia  is  rarely  intense.  Dr. 
Wilks  observes  that  the  most  virulent  cases  of  variola  are  almost  apyretic 
and  devoid  of  feverish  symptoms. 

In  all  the  exanthemata  the  eruption  makes  its  appearance  in  the  throat 
or  the  mouth,  from  twelve  to  twenty-four  hours  (and,  in  many  instances 
longer)  before  it  appears  on  the  cutaneous  surface.  In  smallpox,  in 
scarlet  fever,  in  measles,  in  all  their  grades,  the  eruption  may  be  looked 
for,  with  confidence,  in  this  region  long  before  it  can  be  detected  at  any 
other  point,  and  as  the  eruption  is  often  the  last  link  in  the  chain  of 
evidence  necessary  to  decide  a  question  of  diagnosis,  the  knowledge  of 
this  fact  will  often  relieve  both  physician  and  patient. 

The  eruption  may,  in  smallpox,  often  he  felt  before  it  can  be  seen;  the 
sensation  imparted  to  the  finger  being  like  little  shot  underneath  the  skin. 
Its  first  appearance  is  as  a  simple  red  point  or  pimple,  soon  changing  to 
a  papule.  The  red  blush  of  scarlatina  disappears  on  pressure,  but  is 
immediately  restored  when  the  pressure  is  removed.  It  has  no  decided 
prominence  to  sight  or  feeling.  Previous  to  the  general  boiled-lobster 
appearance  of  scarlatina,  there  is  generally  a  punctate  eruption  and  the 
skin  appears  to  be  rough,  upon  passing  the  hand  over  it,  something  like 
a  nutmeg-grater. 

Dr.  Osler,  of  Montreal,  has  called  attention  to  and  described  a  num- 
ber of  initial  rashes,  which  precede,  by  twelve  to  twenty-four  hours,  the 
appearance  of  the  variolous  eruption.  They  are  principally  noticeable 
on  the  upper  part  of  the  trunk,  and  generally  have  the  similitude  of  a 
deep,  suffused  flush. 

The  pulse  in  variola  is  asserted,  by  some,  to  be  pathognomonic,  and 
significant  so  early  in  the  disease  that  the  malady  can  be  positively  diag- 
nosed many  hours  before  the  eruption  appears.  But  no  definite  descrip- 
tions nor  tracings  of  this  pulse  have  been  given.* 

Having  thus  defined  the  special  indications  for  a  diagnosis  of  these 
diseases  in  their  earliest  stage,  we  give  in  the  following  table  a  synopsis 
of  their  comparative  clinical  history : — 

*  See  Dr.  A.  S.  Payne,  Ya.  Med.  Monthly,  March,  1878 ;  J.  S.  Conrad,  Trans,  of 
the  Med.  and  Chirurg.  Faculty  of  Md.,  1874. 


24  DIFFERENTIAL    DIAGNOSIS. 

ROTHELN.  SCARLET  FEVER. 

INCUBATION. 


Period  of  incubation  from  one  to 
two  weeks. 


Very  uncertain ;  from  a  day  to 
several  weeks ;  on  an  average  about 
twelve  days. 


INVASION. 

Languor;  sbiverings  j  nausea  and]  Shiverings  ;  nausea;  vomiting; 
vomiting;  perhaps  sore  throat,  but  throat  very  much  inflamed  ;  sneezing 
not  severe.  and  discharge  from  the  nose;  con- 

vulsions occasionally  in  children. 
Premonitory  fever  of  short  dura-       Great  heat  of  skin  and  very  fre- 
tion;  relieved  by  the  eruption.  quent  pulse;    not   relieved   by  the 

eruption. 


ERUPTION. 


Appears  early  and  almost  simul- 
taneously over  the  whole  body — is 
sudden  and  general — is  less  marked 
on  the  limbs  than  on  the  trunk, and 
especially  on  the  chest;  may  first 
appear  upon  the  back,  upon  the 
chest  or  neck,  upon  the  cheek  or 
upon  the  forehead;  travels  down- 
ward. 

At  first  minute  dots,  which  rap- 
idly assume  the  appearance  of  large, 
irregular-shaped  patches,  somewhat 
like  measles,  but  less  distinct  in 
color  and  form,  varying  from  three- 
cent  piece  to  twenty-five-cent  piece 
in  size. 

These  patches  are  raised  above 
the  surrounding  skin,  especially  to- 
ward the  middle,  and  are  of  a  darker 
red  color  at  the  centres. 

Fades  in  about  four  days;  des- 
quamation, when  it  occurs,  is  fine 
and  bran-like. 


On  second  day;  first  on  neck,  and 
face,  and  body;  spreads  rapidly  to 
limbs. 


The  skin  feels  harsh  and  rough 
(like  a  nutmeg-grater),  minute  points 
of  redness  next  appear,  soon  sur- 
rounded by  deep  rosy  areola  (like  a 
boiled  lobster). 

The  eruption  is  uniform,  or  in 
very  large  patches,  of  a  scarlet  hue, 
with  interspersed  raised  spots  and 
perhaps  a  few  vesicles;  the  rash  is 
followed,  after  the  seventh  day  of 
its  appearance,  by  complete  desqua- 
mation. 

The  disease  is  communicated  by 
these  epithelial  scales. 


FEVERS. 


25 


MEASLES. 


SMALLPOX. 


INCUBATION. 

Generally  from  seven  to  fourteen  I      Generally   about   ten    days,  but 
days.  I  varies  from  five  to  twenty  days. 


INVASION. 


Lassitude,  shivering,  catarrh  ; 
sneezing,  discharge  from  nose ;  harsh 
cough ;  rarely  vomiting. 

Fever,  with  hot  skin  and  frequent 
pulse ;  rather  increased  by  the  erup- 
tion. 


Shivering,  severe  pains  in  the 
back ;  nausea.  There  may  be  a 
marked  chill  followed  by  vomiting. 

Fever  often  very  violent,  with 
bounding  pulse  and  pain  in  the  loins ; 
great  relief  from  occurrence  of  the 
eruption. 


ERUPTION. 


Appears  on  fourth  day,  first  on 
face,  spreads  gradually  in  forty-eight 
hours  to  the  rest  of  body. 

Comes  out  in  small  circular  dots, 
like  flea-bites.  These  dots  run  to- 
gether and  form  blotches,  of  a  rasp- 
berry color,  and  the  latter  are  very 
prone  to  assume  a  crescentic  or  horse- 
shoe shape,  being  slightly  elevated 
above  surrounding  skin. 

Eruption  is  sometimes  diffused 
over  the  whole  body  in  a  confluent 
form,  and  is  of  a  dull,  deep  red 
color,  offering  a  contrast  to  the  crim- 
son or  scarlet  redness  of  scarlet 
fever. 

Lasts  five  days;  followed  by  in- 
complete desquamation. 


Eruption  at  end  of  third  or  on 
fourth  day;  first  on  lips,  palate  and 
forehead. 

Eruption  is  first  papular;  after 
about  a  day  becomes  vesicular,  then 
pustular;  on  the  eighth  day  of  the 
eruption,  the  pustules  maturate  ; 
about  the  twelfth  the  scabs  begin  to 
fall.  The  danger  of  contagion  does 
not  cease  until  desquamation  is  com- 
pleted. 


26 


DIFFERENTIAL   DIAGNOSIS. 


ROTHELN.  SCARLET  FEVER. 

ACCOMPANIMENTS. 


Only  moderate  sore  throat,  with 
hoarseness  ;  swelling  of  the  neck  ; 
and  rarely  eorv/.a. 

Cerebral  symptoms  absent. 


General  systemicdisturbance  mild. 


Sore  throat;  coryza  or  bronchitis 
rare. 

Tongue  red  ;  raspberry  character. 
Cerebral  symptoms  frequent  and 
grave. 

Marked  systemic  disturbance. 

THERMOMETRY. 

"  The  temperature  always  highest  I      Temperature  may  reach  105.6 c 


on  first  day  of  attack,  not  exceeding 
102°,  next  day  falling  to  100°,  and 
getting  normal  on  the  fifth  day." 
{Fox.) 

"  The  temperature  nearly  always 
sub-febrile  (99.5°  to  100.4°)— some- 
times febrile  (101.3°  to  102.2°)." 
( Wunderlich.) 


No  secondary  fever. 


Minute  particles  of  cuticle,  like 
scales  of  fine  bran. 

Always  begins  toward  centre  of 
the  eruptive  patch,  and  gradually 
extends  to  the  circumference. 


or  even  a  higher  point.  It  usually 
remains  continuously  high  during 
the  eruption,  and  it  is  thus  "well 
distinguished  from  those  affections 
with  which,  on  account  of  other 
symptoms,  it  is  most  easily  con- 
founded, and  more  particularly 
measles  and  rotheln."  ( Wunderlich.) 
It  begins  to  subside  about  the  tenth 
day. 

No  secondary  fever. 

DESQUAMATION. 

Comes  off  in  branny  scales  and  in 
large  patches.  Occasionally  epi- 
dermis of  the  hands  is  detached  en- 
tire, and  may  be  slipped  off  like  a 
glove.    This  is  true  also  of  the  feet. 

Sometimes  several  successive  des- 
quamations occur. 

Is  frequently  accompanied  with 
itching,  which  in  some  cases  is  ex- 
cessive. 

COMPLICATIONS. 

Pneumonia  rare;    pleurisy  more 
I  frequent.    Endocarditis  exceptional. 

SEQUELS. 

Dropsy  rarely;  swelling  and  sup-  Bright's  disease,  dropsy,  conjunc- 
puration  of  the  cervical  glands  not  tivitis,  deafness,  phthisis,  chronic 
uncommon.  diarrhoea,  glandular  enlargement. 

Epidemic,  moderately  contagious.  I      Very  contagious. . 


Pneumonia  rare. 


FEVERS. 


27 


MEASLES.  SMALLPOX. 

ACCOMPANIMENTS. 


Bronchitis,  coryza  and  redness  of 
the  eyes,  very  constant ;  sore  throat 
rare. 

Tongue  coated,  or  red  at  edges. 


Cerebral  symptoms  very  rare  and 
not  severe. 


Sore  throat  and  dry  cough ;  bron- 
chitis rare. 


Tongue   coated   and  swollen,  or 
red  at  edges. 

Cerebral     symptoms,     especially 
convulsions  in  children,  frequent. 


THERMOMETRY. 


Temperature  during  the  prelimi- 
nary fever  may  reach  105°-106°. 
Within  twelve  to  twenty-four  hours 
from  appearance  of  rash  it  sinks 
speedily  to  the  normal.  Protracted 
defervescence  indicates  a  complica- 
tion. 

No  secondary  fever,  though  the 
fever  may  increase  slightly  before 
eruption  leaves. 


Temperature  during  the  prelimi- 
nary fever  high,  often  106°  ;  falls 
rapidly  to  about  100°  after  eruption. 
Rises  again  during  the  secondary 
fever  and  falls  slowly ;  a  slight  rise 
during  desiccation. 


Secondary  fever  well  marked  in 
all  cases. 


DESQUAMATION. 

Always  in  branny  scales,  not  in       In  scabs,  crusts  and  thick  scales, 
patches  or  flakes. 

COMPLICATIONS. 

Catarrhal  pneumonia  is  very  fre-  I      Pneumonia  not  very  frequent, 
quent,  especially  in  adults. 

SEQUELS. 


Chronic  bronchitis,  phthisis,  con- 
junctivitis. 


Contagion  almost  exclusively  lim- 
ited to  children. 


Chronic  diarrhoea,  glandular  en- 
largement, various  diseases  of  the 
eyeballs  and  eyelids. 

Very  communicable  ;  mild  cases 
may  cause  severe  or  malignant  ones. 
Chiefly  adults. 


28  DIFFERENTIAL   DIAGNOSIS. 

TYPHOID  AND  TYPHUS  FEVERS. 

Until  within  comparatively  few  years  these  two  fevers  were  con- 
founded ;  and  although  now,  in  this  country  at  least,  they  are  distinctly 
recognized  as  wholly  different  diseased  conditions,  yet  there  are  numerous 
instances  where  the  clinical  features  of  cases  assimilate  them  to  one  or  the 
other  of  these  conditions,  and  yet  fail  to  answer  satisfactorily  their  cur- 
rently received  definitions.  Such  are  the  numerous  gastric,  nervous, 
simple  continued,  synochal,  mixed,  entero-miasmatic,  typho-malarial,  etc., 
types  which  are  so  often  referred  to  in  medical  literature.  There  are,  in 
fact,  wide  variations  in  the  local  features  of  this  group  of  diseases,  and 
it  is  the  exception  to  find  the  classical  portraits  of  one  of  the  group, 
drawn  in  the  hospital  wards  of  great  cities,  correspond  precisely  with  the 
case  as  seen,  modified  by  the  numerous  special  conditions  of  particular 
regions.  We  shall  cite  some  of  these  modified  types,  after  having 
considered  the  early  symptoms  and  broad  distinctions  of  typhoid  and 
typhus. 

Typhoid  fever  is  peculiarly  a  disease  of  slow  and  insidious  approach. 
For  days,  and  sometimes  for  weeks,  the  patient  is  ailing ;  and  as  this 
gradual  onset  is  known  to  the  public,  the  physician  is  often  called  upon  to 
pronounce  an  opinion  as  to  the  probability  of  the  threatenings  being  of 
typhoid  long  before  any  positive  sign  is  present. 

The  general  symptoms  are  a  sense  of  weakness  and  fatigue,  loss  of 
appetite,  muscular  soreness,  headache,  generally  dull,  sometimes  severe, 
disturbed  sleep,  poor  appetite,  low  spirits.  A  characteristic  and  often 
early  symptom  is  epistaxis.  Frequently  there  is  a  bronchitis,  with  shallow 
and  rather  frequent  breathing,  with  some  sonorous  rales  over  the  chest. 
A  skilled  auscultator  can  often  pronounce  from  the  character  of  the  rale 
as  to  the  presence  of  typhoid,  as  they  yield  a  peculiar,  dry,  ringing  sound. 
In  one  of  his  clinical  lectures,  Dr.  DaCosta  remarks  on  this:  "I  should 
be  loath  to  rest  upon  this  symptom  alone,  but  there  is  something  about  it 
that  often  makes  the  diagnosis  of  typhoid  special  and  specific."*  This 
point  is  worthy  of  further  investigation. 

The  pathognomonic  symptoms  of  typhoid  are  those  connected  with  the 
abdomen.     The  belly  is  swollen  and  tympanitic;  there  is  diarrhoea  with 

*  Medical  and  Surgical  Reporter,  Vol.  xxviii,  p.  11. 


FEVERS.  29 

perhaps  abdominal  pains ;  rumbling  and  tenderness  near  the  ilio-csecal 
valve  and  about  the  right  iliac  fossa.  The  tongue  is  tender,  and  some- 
times moved  with  pain;  the  teeth  show  accumulations  of  dried  mucus 
(sordes);  thirst  is  rarely  excessive;  vomiting  is  rare;  the  mind  is  dull, 
and  the  delirium  is  usually  low  and  muttering.  The  peculiar  eruption 
appears  on  the  chest  and  belly,  most  frequent  between  the  nipple  and 
navel,  about  the  sixth  or  eighth  (never  before  the  fifth)  day  of  the  fever. 
It  is  in  scattered,  small,  reddish,  delible  spots,  resembling  flea-bites. 
Later  they  become  rose-colored,  and  are  surrounded  by  an  area  of 
erythema,  shading  off  into  the  surrounding  skin.  They  are  not  elevated, 
or  very  slightly  so,  and  they  disappear  entirely  on  firm  pressure,  but 
promptly  re-appear.  They  give  no  feeling  of  hardness  to  the  finger 
passed  over  them.  These  spots  are,  however,  often  wholly  absent ;  and 
their  presence,  number  and  size  do  not  seem  to  bear  any  relation  to  the 
severity  of  the  attack. 

The  prodromal  symptoms  above  mentioned  are,  however,  often  varied. 
Dr.  A.  Labeabee,  of  Louisville,  remarks  that  the  characteristics  of  the 
prodromal  stage,  the  lassitude,  epistaxis,  and  even  the  susceptibility  of  the 
bowels  to  purgatives,  which  are  valuable  aids  to  early  diagnosis  in  more 
northern  latitudes,  are  not  so  important  in  the  malarial  regions  of  the 
southern  and  southwestern  United  States;*  and  Dr.  Juegensex,  of 
Kiel,  Prussia,  has  given  the  history  of  a  number  of  cases,  with  the  ana- 
tomical characteristics  of  typhoid  fever,  when  the  attacks  were  sudden, 
with  a  well-marked  chill,  a  high  temperature  (104°  Fah.)  and  quick 
pulse,  swelling  of  spleen  and  little  or  no  diarrhoea,  f  Such  a  course  is 
extremely  rare  in  this  country. 

In  typhus  the  eruption  usually  appears  as  small,  discrete  spots,  slightly 
elevated,  of  a  dingy  red  color  and  not  completely  fading  on  pressure.  In 
a  short  time  the  spots  cease  to  be  elevated,  and  fade  less  on  pressure,  and 
a  purple  mottling  appears  in  the  interjacent  portions  of  skin.  At  a  still 
later  period — say  on  the  eighth,  ninth  or  tenth  day — the  spots  become 
entirely  petechial,  not  being  at  all  affected  by  pressure.  The  eruption 
begins  to  fade  about  the  ninth  or  tenth  day,  and  disappears  about  the 
fourteenth,  and,  if  there  be  no  local  complication  and  the  patient  has  not 

*  Trans.  Kentucky  State  Med,  Soc,  1876,  p.  123. 
\  Med.  Times  and  Gazette,  1874. 


30  DIFFERENTIAL   DIAGNOSIS. 

been  very  greatly  prostrated,  convalescence  is  established  between  that 
day  and  the  twenty-first.  In  slighter  cases,  however,  the  serious  illness 
may  continue  for  only  about  a  week,  the  eruption  may  never  be  very 
marked,  and  the  patient  may  become  convalescent  from  the  tenth  to  the 
fourteenth  day;  while,  in  very  severe  cases  the  rash  may  become  petechial 
at  an  early  period,  and  may  continue  on  the  skin  till  near  the  end  of  the 
third  week,  and  the  convalescence  may  be  very  greatly  protracted. 
Generally,  in  a  simple  uncomplicated  case  of  typhus,  the  pulse  and  tem- 
perature fall  below  the  normal  standard  at  the  earlier  period  of  convales- 
cence, and  again  rise  when  the  patient  takes  more  food  and  is  capable  of 
some  little  muscular  exertion.  Usually  the  bowels  are  confined  during 
the  course  of  the  disease,  but  such  is  not  always  the  case ;  sometimes 
towards  the  height  of  the  fever  and  when  there  is  great  prostration  of 
strength,  the  bowels  are  relaxed,  apparently  from  want  of  power  in  the 
sphincter  to  retain  the  fecal  matter;  but  in  some  cases  there  is  profuse 
diarrhoea  during  the  whole  course  of  the  disease,  and  this  independently 
of  any  medicine.  It  is  impossible  to  base  the  diagnosis  between  typhus 
and  typhoid  upon  the  confined  state  of  the  bowels  in  the  former  disease 
and  the  occurrence  of  relaxation  in  the  latter,  for  it  is  not  uncommon  for 
the  bowels  to  be  confined  in  typhoid.  So,  also,  though  as  a  rule  the 
cerebral  disturbance  is  more  marked  in  cases  of  typhus  than  in  typhoid, 
it  sometimes  happens  that  a  patient  will  pass  through  a  marked  or  even 
severe  attack  of  typhus  without  much  delirium,  and  retaining  his  intelli- 
gence to  such  an  extent  as  to  be  able  to  answer  simple  questions  put  to 
him,  without  any  apparent  difficulty.  In  such  cases,  however,  the  patient, 
on  recovery,  has  no  recollection  of  anything  that  has  occurred  from  a 
very  early  period  of  his  illness  till  convalescence  is  far  advanced. 

In  the  following  table,  the  leading  jjhenomena  of  the  two  diseases,  as 
given  by  the  best  authorities,  are  contrasted,  for  the  purpose  of  estab- 
lishing their  clinical  distinction.  The  non-identity  of  the  two  affections 
is  now  everywhere  acknowledged.  (In  Germany  typhoid  is  often  called 
abdominal  typhus;  an  unfortunate  title.) 


FEVERS. 


31 


TYPHOID. 

Age  generally  from  eighteen  to 
thirty-five. 

Not  directly  contagious;  often 
sporadic. 

Attack  generally  insidious. 

Duration  fully  three  weeks ;  often 
much  longer. 

Death  hardly  ever  before  end  of 
second  week;  more  generally  in  or 
after  third  week. 

Cerebral  symptoms  come  on  grad- 
ually; last  longer. 


Great  emaciation. 

Face  pale,  or  flush  confined  to 
cheeks. 

Skin  hot,  sometimes  covered  with 
acid  perspiration. 

Abdominal  symptoms,  such  as 
diarrhoea,  tympanites;  intestinal 
hemorrhage  not  unusual. 

Epistaxis  common. 

Bronchitis  and  sometimes  pleu- 
risy. 

Eruption  light  red  and  not  on 
extremities. 

Autopsy  shows  morbid  state  of 
Peyer's  patches  and  solitary  glands ; 
enlargement  of  mesenteric  glands  ; 
ulceration  of  mucous  coats  of  intes- 
tines ;  enlargement  and  softening  of 
spleen  ;  ulceration  of  the  pharynx. 


TYPHUS. 

At  all  ages,  often  in  persons  be- 
yond middle  life. 

Highly  contagious,  generally  epi- 
demic. 

Attack  generally  sudden  ;  no 
lengthened  prodromata. 

Duration  somewhat  shorter;  often 
not  prolonged  beyond  second  week. 

Death  not  unfrequently  at  end  of 
first  week,  and  often  before  conclu- 
sion of  second. 

Delirium  or  decided  stupor  comes 
on  soon,  sometimes  almost  from  the 
onset;  headache  has  appeared  and 
disappeared  by  about  the  tenth  day. 

Less  emaciation ;  greater  prostra- 
tion. 

Face  deeply  flushed,  of  dusky 
hue ;   eye  injected. 

Skin  of  pungent  heat,  sometimes 
emitting:  an  ammoniacal  odor. 

No  abdominal  symptoms;  bowels 
constipated ;  meteorism  rare ;  no  in- 
testinal hemorrhage ;  sometimes  acute 
dysentery  during  convalescence. 

No  epistaxis. 

Pneumonia,  or  marked  congestion 
of  the  lungs,  and  bronchitis  of  finer 
tubes. 

Eruption  darker  color  and  all 
over  the  body. 

No  constant  post-mortem  appear- 
ances ;  most  common  are  dark-col- 
ored, liquid  blood,  and  enlargement 
of  the  spleen;  softening  of  heart 
more  common  than  in  typhoid  ;  no 
intestinal  lesions. 


32 


DIFFERENTIAL   DIAGNOSIS. 


COMPARATIVE  THERMOMETRY  (DR.  J.  W.  MILLER). 

TYPHOID.  TYPHUS. 


The  duration  of  elevated  tempera- 
ture is  verv  rarelv  less  than  twentv- 


one  days  ;  it  is  generally  longer,  and    days  ;  it  is  generally  shorter  by  sev 

eral  days,  and  may  be  even  so  short 
as  nine  days. 


may  be  protracted  to  thirty-five  days 
or  even  more. 

The  evening  temperature  is  al- 
most constantly  higher  than  that  of 
the  morning. 

The  difference  between  the  morn- 
ing and  evening  temperature  is  gen- 
erally, throughout  the  case,  greater 
than  in  typhus  ;  and  toward  the  end 
of  the  fever  there  occurs  the  very 
characteristic  oscillation  of  tempera- 
ture, during  which  the  difference  is 
frequently  five,  six,  or  even  seven 
degrees,  and  which  may  continue 
from  a  few  days  to  a  week  or  more. 

A  high  temperature  is  frequently 
accompanied  by  a  pulse  but  slightly 
accelerated,  and  occasionally  by  a 
pulse  slower  than  normal,  and  not 
infrequently  dicrotic,  especially  dur- 
ing convalescence. 


The  duration  of  elevated  tempera- 
ture is  very  rarely  beyond  eighteen 


The  evening  temperature  is  fre- 
quently lower  than  that  of  the  morn- 
ing. 

The  difference  between  the  morn- 
ing and  evening  temperature,  during 
the  heiglit  of  the  fever,  or  from 
about  the  third  to  the  tenth  or  elev- 
enth day,  is  comparatively  seldom 
above  one  degree,  and  although  about 
the  period  of  defervescence  the  dif- 
ference is  sometimes  much  greater ; 
the  oscillation  is  not  continued  over 
more  than  one  or  two  days. 

A  high  temperature  is,  as  a  rule, 
accompanied  by  a  high  pulse. 


The  varieties  of  fever  called  gastric  and  nervous  have  not  been  recog- 
nized as  distinct  types  by  the  most  recent  writers.  Yet  there  is  no  doubt 
that  many  cases  of  continuing  fever  present  gastric  rather  than  abdominal 
symptoms,  and  various  other  perceptible  variants  from  the  type  of  a  mild 
typhoid.  The  following  semeiological  table,  drawn  from  Dr.  Copland's 
work,  will  illustrate  this  : — 


FEVERS. 


33 


FORMS  OF  TYPHOID. 


SIMPLE  CONTINUED  TYPE. 

100-120,  small,  weak,  irregular ; 
intermittent  when  a  dangerous 
attack. 

Heat  of  surface  generally  rises 
over  100°. 


NERVOUS  TYPE. 

Pulse.  Soft,  feeble,  and  quick  :  about 

eleventh  day  very  quick  and  un- 
equal. 

Temperature.  Heat  of  skinnotmueb  <]<■•  in<   I: 

it  may  even  seem  natural  or  di- 
minished. 

Tongue.  Loaded  or  covered  with  a  dirty 

mucus,  afterward  brown  or  black, 
incrusted  or  fissured. 

Fetor  of  the  breath  and  of  the 
discharges,  an  irregular  relaxed 
state  of  the  bowels,  pain  at  the 
epigastrium,  nausea  and  vomiting. 

Countenance  pallid  or  tran- 
siently flushed,  head  heavy,  con- 
tinual restlessness,  want  of  sleep, 
tremor,  hearing  dull,  unconscious 
evacuations,  low  delirium,  early 
stupor  and  coma. 

The  bronchial  surface  is  the 
part  chiefly  affected ;  substance  of 
the  lungs  sometimes  complicated. 

Sore-throat,  occasionally  so  se- 
vere as  to  resemble  an  attack  of 
anginose  maligna. 

Often    announced    by   a 

crisis. 


Gastric 
Symptoms. 


Head 
Symptoms. 


Lung 
Symptoms. 

Affection  of 
Throat. 

Recovery. 


true 


White,  foul,  loaded  or  furred  ; 
again  red  at  its  sides,  and  point 
loaded  with  dirty  yellow  fur. 

Tenderness  at  epigastrium  ; 
looseness  or  diarrhoea  of  an 
ochery  hue  ;  vomiting  early. 

Pain  in  head,  throbbing  of 
arteries,  brilliant  expression  of 
eyes,  marked  acuteness  of  senses, 
watchfulness  and  restlessness, 
moaning  and  incoherent  mutter- 
ing, dilated  pupils,  and  coma. 

A  common  and  early  complica- 
tion, either  to  bronchial  surface 
or  congestion  of  substance. 

Sore-throat  or  inflammation  of 
fauces  sometimes  accompany. 

By  subsidence  of  the  prominent 
morbid  actions  indicative  of  a 
gradual  decline. 

Gastric  fever,  which  is  not  to  be  confounded  with  gastritis  (although 
this  is  more  properly  a  fever  of  gastric  origin),  is  recoguized  by  Niemeyer 
and  other  competent  authorities  as  a  separate  type.  It  commences  with 
loss  of  appetite,  headache  and  languor,  followed  by  a  slight  chill,  with 
marked  gastric  irritability,  great  nausea,  frequent  vomiting,  and  consti- 
pation. There  is  considerable  tenderness  on  pressure  over  the  stomach, 
a  low  pulse  (60  to  70  per  minute),  and  a  temperature  at  first  risino- 
slightly  to  (100°  Fahr.),  then  falling  below  the  normal  as  the  disease 
advances  (to  95°  and  even  lower).  A  grave  symptom  is  double  vision  or 
total  loss  of  sight.  There  are  no  tympanites,  diarrhoea,  delirium,  sub- 
sultus  tendinum,  spots,  iliac  tenderness,  nor  sordes,  as  in  typhoid.  \Yomen 
are  more  liable  to  it  than  men,  old  persons  than  those  of  middle  ao-e  or 
youth.     Its  outbreaks  indicate  it  to  be  a  zymotic  disease,  and  the  mor- 


34 


DIFFERENTIAL   DIAGNOSIS. 


tality  is  even  higher  than  in  typhoid.  The  pathognomonic  symptom  of 
the  disease  is  the  peculiar  sweetish  odor  of  the  breath;  it  is  likened  by 
some  to  the  odor  arising  from  hot  water  poured  on  garlic,  having  a 
slightly  alliaceous  odor;  or,  according  to  others,  it  resembles  a  faint 
aroma  of  valerianic  acid.* 

Typhlitis  can  readily  be  distinguished  from  typhoid  fever  by  the  path- 
ognomonic sign  of  a  dense  tumor  in  the  iliac  fossa,  increasing,  and 
exceedingly  tender  on  pressure. 

TYPHOID  AND  MALARIAL  FEVERS. 

TYPHO-MALARIAL  (Woodward),     ENTERO-MIASMATIC     (Wood),     OR 
REMITTO-TYPHUS  (Drake). 

In  order  to  bring  into  relief  the  broad  distinctions  between  the  typhoid 
and  malarial  fevers  when  in  their  typical  forms,  the  following  compara- 
tive table  has  been  prepared,  which  is  chiefly  that  of  Dr.  E.  M.  HuME.f 

TYPHOID. 

Cause. 


Decomposing  animal  and  vege- 
table matter,  especially  human 
excrement. 

Old  soil ;  may  be  high  and  dry 
and  long  settled,  especially  where 
saturated  with  sewage. 

Epidemic  of  typhoid  fever. 

Seldom  after  forty. 

Continued  without  intermission 
or  decided  remissions. 

Lasts  three  or  four  weeks  ;  can- 
not be  cut  short. 

Great  nervous  disturbance  and 
prostration  ;  dull,  heavy,  throb- 
bing, persistent  frontal  headache ; 
twitching  of  muscles  ;  tickling  of 
throat ;  ringing  in  ears  ;  deafness  ; 
mind  stupid. 

Asthenic,  not  wild. 

Frequent. 

Catarrhal  bronchitis  with  some- 
times tough,  tenacious  sputa. 


Locality. 


MALARIAL. 

Emanations  from  marshes, 
damp,  low  or  new  soil  ;  always 
vegetable,  never  animal. 

New  land,  moist,  low  and 
swampy. 


Circumstantial 
Evidence. 

Prevalence  of  malarial  disease. 

Age. 

All  ages. 

Periodicity. 

There  is  either  intermission  or 

remission. 

Duration. 

Can  be  interrupted  and. cured 
in  a  few  days. 

Nervous  impli- 
cation. 

None,  although  there  is  some- 
times severe  headache,  simula- 
ting meningitis. 

Delirium. 

Sthenic. 

Epistaxis. 

None. 

Lungs. 

Congested,    when    affected    at 

all. 


*  Dr.  G.  B.  Ballard,  Trans,  of  the  Vt.  Med.  Soc.  1877,  pp.  52-56. 
f  Peninsular  Journal  of  Medicine,  Feb.,  1875. 


FEVERS. 


3D 


TYPHOID. 

From  70  to  140  beats  per  rain-  Pulse. 

ute,  small,  irregular  or  dicrotic. 

Hot,  even  when  moist ;    emits  Skin, 

a  peculiar,  musty  odor,  pathog- 
nomonic of  this  fever. 

Indicates  an  increase  of  tem-  Thermometer. 
perature  from  morning  to  even- 
ing of  about  2  deg. ,  and  a  de- 
crease of  1  deg.  from  night  to 
morning ;  commences  first  day 
98.5  deg.,  reaches  its  maximum 
of  104  deg.  on  the  morning  of 
the  fourth  day ;  from  this  time 
the  evening  temperature  ranges 
between  103  deg.  and  104  deg., 
morning  1  deg.  lower,  until  end 
of  second  week,  when  it  gradually 
declines  in  the  same  regular  man- 
ner, always  lower  in  the  morning 
than  in  the  evening,  except  when 
there  is  a  complication. 

Protrudes  tremblingly  ;  is  cov-  Tongue, 

ered  with  a  whitish  yellow  coat, 
which  subsequently  disappears 
and  is  replaced  by  a  dry,  pale 
brown  one,  with  red,  glazed  tip 
and  edges ;  teeth  covered  with 
dark-brown  sordes. 

Pale,  livid,  muddy,  or  may  be       Complexion 
clear,  with  cheeks  flushed. 

Foaming,  light  color,  free  from  Urine. 

sediment ;  frequently  contains 
albumen  ;  has  typhoid  odor  like 
body. 

Diarrhoea,    except   in    mildest        Excretions 
cases  ;  stools  offensive,  pea  soup,      from  Bowels. 
bright  yellow  or  brown ;    devoid 
of  mucus,  but  sometimes  contains 
whitish  flocculi. 

Tympanites  occurs,  giving  tub         Abdomen, 
shape  to  abdomen  ;  pressure  over        shape,  etc. 
cascum  produces  pain  and  gurg- 
ling   sound  ;      tenderness     over 
spleen. 

Stomach  not  involved ;  no  se-  Pain. 

vere  pain  anywhere,  except  when 
peritonitis  occurs. 


MALARIAL. 

More  frequently  high,  full  and 
bounding. 

Varies ;  sometimes  dry  and 
hot ;  odor  acid  and  swampy  ;  at 
other  times  may  be  normal. 

Rises  rapidly  to  105  deg.  or 
more  first  day  or  two,  and  falls 
suddenly  ;  is  not  so  uniform  ;  may 
rise  and  fall  seven  degrees  in  one 
day. 


Coated  all  over  with  a  heavy, 
dark  yellow  coat.     No  sordes. 


Sallow  ;  eyes  yellow. 

Dark  color,  turbid,  no  albu- 
men, except  in  malarial  hemor- 
rhagic fever. 

Bowels  costive  ;  dark,  hard, 
dry,  bilious  stools. 


No  tympanites  or  tenderness  of 
abdomen. 


Gastric  disturbance  and  vomit- 
ing of  bile  ;  pain  in  stomach  and 
elsewhere  very  intense  ;  may  be 
throughout  the  entire  body. 


36 


DIFFERENTIAL   DIAGNOSIS. 


MALARIAL. 

Eruptions  of  different  kinds 
sometims  occur,  but  are  so  dif- 
ferent in  shape,  feel,  duration, 
number,  extent  and  place,  thai 
they  need  never  be  mistaken  for 
the  typhoid  eruption. 


Very  slight — not  one  fatal  case 
in  a  hundred. 

Hemorrhage  from  congestion 
of  bowels  rare ;  congestion  of 
stomach,  lungs,  liver  and  spleen, 
the  two  latter  sometimes  become 
enlarged. 


TYPHOID. 

Occurs   during   second   week  ;  Eruption. 

from  one  to  twenty  small  rose- 
colored  spots,  size  of  pin  bead, 
appear  on  abdomen,  chest  or 
back  :  do  not  extend  to  extremi- 
ties; present  no  distinct  elevation 
to  the  touch,  disappearing  upon 
pressure,  but  reappearing  upon 
its  removal  ;  last  about  three 
days  :  fade  away  and  a  fresh  crop 
appears.  This  eruption  is  claimed 
to  be  "peculiarly  and  absolutely 
diagnostic  of  typhoid  fever." 
Later  in  the  disease  sudamina 
appear. 

Great — averages  one  in  five.  Mortality. 

Inflammation  and  ulceration  of  Lesions. 

Peyer's,  solitary  and  Brunner's 
glands  ;  sometimes  perforation  of 
bowels  with  peritonitis,  and  fatal 
hemorrhage ;  inflammation  and 
enlargement  of  mesenteric  glands 
and  the  spleen  (which  sometimes 
bursts) ;  the  brain,  stomach,  liver 
and  lungs  sometimes  inflamed. 

We  shall  now  consider  the  character  of  a  disease  presenting  in  its  dif- 
ferent stages  symptoms  both  of  malarial  and  typhoid  fever. 

The  experience  of  numerous  observers  has  proven  that  there  is  a  com- 
plex form  of  fever  prevalent  in  malarious  districts,  in  which  the  typhoid 
and  miasmatic  elements  are  combined.  It  has  been  proposed  by  Dr.  J. 
J.  Woodward  to  call  this  "  typho-malarial  fever,"  a  term  which  he 
explains  to  be  applied  "  not  to  a  specific  or  distinct  type  of  disease,  but 
to  the  compound  forms  of  fever  which  result  from  the  combined  influence 
of  the  causes  of  the  malarious  fevers  and  of  typhoid  fever."* 

The  name  Remitto- Typhus  was  given  to  it  by  Dr.  D.  Drake,  who  also 
spoke  of  it  as  "  the  typhoid  stage  of  remittent  or  autumnal  fever."  He 
does  not  consider  it  a  distinct  disease,  but  a  genuine  hybrid  of  typhoid 
and  remittent  fevers.  He  remarks  that  in  many  cases  the  stage  of  inva- 
sion is  nearly  the  same  length  in  both ;  both  attack  males  more  than 
females ;  and  that  when  remittent  terminates  fatally ;  subsultus  tendinum, 
a  dry  tongue  and  intestinal  hemorrhage  are  sometimes  present.  He  has, 
*  Transactions  of  the  International  Medical  Congress,  1870,  p.  340. 


FEVERS. 


37 


however,  never  seen  a  decided  intermittent  pass  into  typhoid  ;  nor  well- 
marked  typhoid  terminate  in  an  intermittent.* 

During  and  since  the  war,  typho-malarial  fever  has  attracted  much 
attention,  and  its  traits  have  been  thus  distinguished  from  simple 
typhoid : — 

TYPHO-MALARIAL. 
Only    in    miasmatic     localities ; 


TYPHOID. 

Occurs  in  all  localities,  most  com- 
mon in  the  north. 

Invasion  gradual  and  without  re- 
in ittence. 

Daily  exacerbation  and  remission 
slight. 

Diarrhoea  the  rule.  Tympanites 
common.  Abdominal  tenderness 
considerable  ;  epigastric  and  hepatic 
tenderness  slight. 

Temperature  comparatively  low. 
Delirium  low  and  muttering. 

Spleen  not  involved  to  the  same 
extent. 

Sordes  on  the  teeth  the  rule. 

Peyer's  glands  always  involved. 

Rose-colored  eruption  present. 

Pigment  deposits  absent. 


most  common  in  the  south. 

Often  begins  as  simple  intermit- 
tent or  remittent. 

Decidedly  marked. 

Constipation  the  rule.  Tympanites 
rare.  Abdominal  tenderness  slight ; 
epigastric  and  hepatic  tenderness 
considerable. 

Temperature  high,  especially  at 
outset.     Delirium  active. 

Tumefaction  of  spleen  very 
marked. 


Sordes  rare. 

Rarely  involved. 

Generally  entirely  absent. 

Pigment  deposits  in  various  tis- 
sues and  organs  very  common. 

THE  TYPHOID  STATE. 


It  is  a  common  error  to  confound  the  typhoid  condition  which  occurs 
in  many  diseases  with  typhoid  fever,  properly  so-called.  This  typhoid 
state  may  be  developed  in  typhus  and  other  fevers,  in  acute  pneumonia, 
rheumatism,  tuberculosis,  pysemia,  and  various  renal  diseases,  especially 
the  granular  or  gouty  kidney,  and  Bright's  disease.  The  exciting  cause 
in  all  these  cases,  it  is  believed,  is  the  accumulation  in  the  blood  of  the 
nitrogenous  products  of  disintegration  of  the  tissues. 

The  so-called  "  typhoid  symptoms"  are  a  quick,  soft  pulse ;  a  dry, 
*  "  Diseases  of  the  Interior  Valley  of  North  America,"  p.  556. 


38 


DIFFERENTIAL   DIAGNOSIS. 


browD  tongue;  the  phenomena  and  physical  signs  of  hypostatic  congestion 
of  the  lungs ;  impairment  of  the  mental  faculties ;  stupor  passing  into 
coma;  delirium,  which  is  at  one  time  acute  and  noisy,  at  another  low  and 
muttering,  and  not  unfrequently  associated  with  muscular  tremor;  invol- 
untary discharges.  The  skin  is  dusky,  moist  and  often  emitting  a  fetid 
odor.  There  is  little  thirst  and  often  difficulty  in  swallowing.  The 
temperature  and  urine  vary  considerably.  The  respirations  are  shallow 
and  somewhat  accelerated.  The  bowels  are  sometimes  constipated,  but 
often  relaxed  with  offensive  evacuations. 

The  difference  between  this  condition,  as  it  supervenes  in  the  above 
named  diseases,  and  true  typhoid,  or  continued  fever,  may  be  thus 
presented : — 

TYPHOID  FEVER. 

Begins  without  any  history  of 
preceding  disease. 

Can  often  be  traced  to  an  external 
zymotic  or  septic  influence. 

Diarrhoea,  tympanites,  epistaxis, 
tenderness  over  intestinal  glands, 
pain  in  iliac  fossa. 

Eruption  of  rose-colored  spots. 


THE  TYPHOID  STATE. 

Arises  in  the  course  of  an  ante- 
cedent local  disease. 

Is  always  traceable  to  blood-poi- 
soning from  deficient  elimination. 

Abdominal   symptoms  generally 
absent. 


Occasionally  there  may  be  spots 
of  diffused  rosiness,  from  dilatation 
of  superficial  capillaries,  but  nothing 
like  the  tdches  rouges. 

Intestinal  hemorrhage  not  to  be 
expected. 

Ague-cake  not  usual,  except  in 
malarious  cachexia. 

Urine  may  show  albumen  or  pus. 


Intestinal   hemorrhage  not  infre- 
quent. 

Enlargement  of  spleen  very  con- 
stant. 

Albumen  and  pus  not  present. 


MALARIAL  FEVERS. 

The  characteristic  symptom  of  all  malarial  diseases  is  'periodicity.  It 
is  not,  however,  pathognomonic;  for  hectic  and  syphilitic  fevers,  neural- 
gia and  many  other  diseases,  simulate  this  trait  very  closely.  The  diag- 
nosis, however,  in  most  instances  is  facile. 

Intermittent  begins  with  a  chill,  cold  extremities,  pale  face,  chattering 


FEVERS.  39 

teeth  and  pulse  feeble  ;  followed  by  a  decided  fever,  the  face  flushed,  the 
skin  hot,  the  pulse  full  and  rapid;  and  ends  with  a  profuse  perspiration, 
soft,  moderate  pulse,  and  restoration  of  the  secretions.  This  recurs  at 
definite  intervals,  with  complete  intermissions  between. 

In  remittent  fever  we  find  the  same  development  of  the  phenomena, 
the  chill,  the  fever,  the  perspiration,  but  without  complete  abatement  of 
the  febrile  symptoms  in  the  interval.  They  continue,  though  lessened, 
and  usually  have  daily  exacerbations.  It  is  generally  preceded  by  inter- 
mittent. 

Between  these  two  most  common  forms  there  are  the  differences  that 
in  intermittent  the  patient  is  well  between  the  paroxysms  ;  in  remittent 
he  continues  ailing;  in  intermittent  a  distinct  chill  precedes  each  attack  ; 
in  remittent  the  chill  is  slight  or  absent ;  in  intermittent  the  appetite  is 
good  between  the  invasions  ;  in  remittent  nausea  and  anorexia  are  present. 
Dr.  Daxiel  Drake  says :  "  If  we  suppose  an  ague  shake  to  be  reduced 
to  a  mere  chill,  but  the  subsequent  hot  stage  aggravated  and  prolonged, 
we  shall  form  a  just  conception  of  the  relations,  in  symptomatology, 
between  intermittent  and  remittent  fever."* 

The  more  intense  cases  of  malarial  poisoning  develop  algid  pernicious 
or  congestive  chills,  malignant  remittent  fever,  and  malarial  hemorrhagic 
fever. 

In  congestive  chill  the  symptoms  of  an  ordinary  intermittent  are 
present,  but  in  an  exaggerated  form.  The  chill  is  intense,  the  skin  and 
even  the  breath  seem  cold ;  the  face  is  cadaveric ;  the  respiration  is  sigh- 
ing ;  the  pulse  scarcely  distinguishable ;  the  shivering  shakes  the  bed. 
When  the  stage  of  fever  comes  on  the  pulse  is  full  and  so  quick  that  it 
can  scarcely  be  counted ;  the  skin  of  the  body  is  hot  while  the  feet  and 
hands  are  cold ;  delirium  is  active ;  thirst  intense ;  the  stomach  is 
irritable.  The  perspiration  that  follows  brings  no  relief;  the  patient 
lies  prostrate  and  sometimes  unconscious.  When  the  congestion  affects 
the  lung  there  is  a  sense  of  smothering,  difficult  breathing  and  bloody 
expectoration  ;  when  it  attacks  the  stomach  and  bowels  there  are  violent 
spells  of  vomiting,  foaming  or  soap-like  white  discharges,  and  great 
epigastric  tenderness.  In  these  cases  the  mind  is  usually  clear ;  but 
when  it  is  the  brain  which  is  involved,  there  is  intense  headache,  the 
*"  Diseases  of  the  Interior  Valley  of  North  America,"  p.  95. 


40  DIFFERENTIAL   DIAGNOSIS. 

mind  is  dull  or  delirious,  and  coma  is  apt  to  supervene.     Patients  rarely 
survive  the  third  chill  of  this  intensity. 

The  diagnosis  of  malignant  remittent  has  been  carefully  set  forth  by 
Dr.  Daniel  Drake  as  follows : — 

1.  The  pulse  does  not  rise  in  fullness  and  force  during  the  exacerba- 
tion, as  in  other  forms  of  remittent  fever,  but  is  generally  small, 
frequent,  weak  and  variable.  When  the  remission  begins  it  generally 
improves  slightly,  but  to  a  much  less  extent  than  in  mild  remittents. 

2.  The  feeling  of  abdominal  oppression,  and  the  anxiety,  restlessness 
and  gastric  irritability  are  deeper  in  this  than  in  other  forms  of  remittent 
fever ;  and  these  symptoms  never  entirely  cease  during  the  remission. 

3.  A  coldness  in  the  hands  and  feet,  or  of  the  ends  of  the  toes  and 
fingers  only,  continues  through  the  hot  stage,  while  the  trunk  of  the  body 
and  the  head  are  in  high  fever  heat.  With  the  arrival  of  the  remission 
this  coldness,  in  milder  cases,  is  replaced  by  a  natural  temperature ;  but 
in  the  more  malignant  it  continues.  Many  experienced  physicians 
regard  this  as  the  most  characteristic  sign  of  malignant  remittent. 

4.  There  is  no  time  when  the  fever  is  absent ;  and  whatever  irrita- 
tions or  congestions  are  formed  in  the  cold  stage,  and  whatever  inflamma- 
tions are  set  up  in  the  hot  stage,  remain,  though  moderated  in  degree, 
throughout  the  remission.* 

Hemorrhagic  malarial  fever  commences  with  a  chill  of  the  congestive 
type ;  and  during  the  first  paroxysms  the  symptoms  which  distinguish 
this  from  all  other  fevers  usually  make  their  appearance.  These  are 
jaundiced  skin,  and  vomiting,  apparently  without  any  effort,  of  a  dark 
fluid ;  the  faeces  dark,  offensive,  and  tawny  looking ;  the  color  of  the 
skin  yellowish  or  bronzed,  and  the  urine  colored  with  blood.  The  last 
mentioned  is  pathognomonic.  Sometimes  the  urine  is  profuse,  though 
mixed  with  blood,  which  is  a  favorable  symptom.  Most  of  such  cases 
recover ;  but  when  the  urine  grows  scanty,  and  suppression  ensues,  the 
result  is  said  to  be  always  fatal.f  The  remissions  are  irregular  and 
often  ill-defined;  and  after  the  hot  stage  there  is  no  perspiration.  J  Pain 
in  the  back  is  severe  and  incessant ;  the  stomach  is  irritable,  and  the 
mental  powers  often  obscured. 

*  Loc.  cit. 

f  Dr.  Greensville  Dowell,  "Yellow  Fever  and  Malarial  Fever,"  p.  213. 

%  Dr.  Thackeu,  Cincinnati  Medical  News,  1872. 


FEVERS.  41 

The  tongue  presents  in  malarious  diseases  some  peculiar  appearances. 
One  of  these  has  been  described  as  follows  by  Dr.  Wm.  A.  Love,  of 
Atlanta  :* — 

/'While  the  appearance  of  the  tongue  indicative  of  physiological  and 
pathological  conditions  of  the  alimentary  mucous  membrane  presents 
itself  on  the  upper  papilla  ted  surface,  the  border  and  outer  edges  present 
the  peculiarity  indicative  of  malarial  toxsemia.  It  consists  in  a  peculiar 
pectiniforme  appearance  of  the  edges  of  the  tongue,  as  though  these 
edges  had  been  under  the  pressure  of  the  sides  of  the  teeth  of  a  comb — 
just  as,  in  certain  "  languid  and  flabby  "  states  of  the  prima?  vise,  we 
find  the  edges  presenting  a  crenated  appearance,  produced  by  the  indenta- 
tions resulting  from  the  pressure  of  the  teeth  in  the  oral  cavity — -just 
within  this  pectiniforme  edge,  making  the  outer  border  of  the  upper 
surface  of  greater  or  less  width,  in  different  cases;  or  in  different 
degrees  of  malarial  toxaemia  there  appears  a  smooth  margin,  both  the 
pectiniforme  edge  and  the  smooth  margin  presenting  a  cleaner  appearance 
and  a  brighter  hue  than  the  other  portions  of  the  surface  of  the  organ." 

A  characteristic  color  of  the  tongue  in  malarial  poisoning  has  been 
observed  by  Professor  Charles  O.  Cijrtman,  m.d.,  of  St.  Louis. 
He  describes  it  as  almost  uniformly  present.  The  color  of  the  dorsum 
of  the  tongue  as  far  back  as  the  circum vallate  papillae  is  of  a  bluish  gray 
tinge,  somewhat  resembling  that  of  old  sheet  zinc  or  lead.  It  occurs  in 
various  degrees  of  intensity,  giving  the  impression  of  a  coloring  of 
greater  or  less  thickness,  superimposed  upon  the  epithelial  surface,  some- 
times quite  thin  and  transparent,  at  other  times  quite  opaque.  In  some 
cases  this  hue  is  observed  without  any  other  pronounced  symptoms  of 
malaria ;  but  in  all  such  the  distinct  malarial  symptoms  follow.  The 
disappearance  of  this  color  serves  as  a  valuable  index  of  the  perfect 
restoration  to  health. f 

The  symptoms  of  malarial  poisoning  are  multiform,  and  are  frequently 
so  masked  and  disguised  that  the  closest  observation  fails  to  detect  their 
origin.  This  is  the  condition  of  malarial  toxaemia.  It  is  broadly 
characterized  by  a  tendency  to  cerebral,  thoracic  and  abdominal  con- 
gestion, obstinate  to  ordinary  remedies,  and  often  slightly  periodic  in 

*  "  Transactions  of  the  Medical  Association  of  Georgia,  1878." 
f  St.  Louis  Medical  and  Surgical  Journal,  1869. 


42  DIFFERENTIAL    DIAGNOSIS. 

exacerbations.  Bronchitis,  diarrhoea,  simple  fever,  toothache,  neuralgia, 
ophthalmia,  urticaria  and  other  skin  diseases,  even  haemoptysis,  hysteria 
and  rheumatism,  may  all  be  caused,  instituted,  or  simulated  by  this 
subtle  poison. 

Careful  examination  will  sometimes  disclose  evidence  of  periodicity  in 
an  increase  of  suffering  at  regular  periods;  sometimes  at  intervals  of 
several  days,  or  even  weeks,  apart;  or  they  may  be  regularly  aggravated 
at  morning,  noon  or  night.  Sometimes  subordinated  to  the  prominent 
symptoms,  and  apt  to  be  overlooked  by  the  patient  unless  particular 
inquiry  is  made,  are  slight  recurrent  headaches,  intolerance  of  light, 
shiverings,  or  a  sense  of  cold,  or  alternating  heat  and  cold,  or  perspira- 
tions. A  trace  of  blood  in  the  urine,  especially  in  the  tropics,  is  a 
common  indication  of  malaria.  Nausea  or  vomiting,  or  a  copious  watery 
discharge  from  the  bowels  at  periodic  intervals,  are  often  observed, 
especially  in  children.*  The  skin  is  harsh,  dry,  and  presents  a  muddy 
or  else  a  greenish-yellow  hue,  which  is  most  noticeable  on  the  face,  neck 
and  arms.  The  appetite  is  capricious,  the  strength  easily  exhausted,  the 
temper  irritable,  the  mind  readily  depressed,  and  the  energies  diminished. 
On  careful  percussion  the  spleen  is  nearly  always  found  to  be  decidedly, 
and  the  liver  slightly,  larger  than  in  health. 

The  condition  of  the  blood  in  malarial  poisoning  has  been  studied 
with  definite  results.  Dr.  A.  Kelsch  has  found  that  the  white  cor- 
puscles diminish  during  an  attack  to  one-half  or  one-third  of  their 
normal  number,  and  continue  less  than  usual  so  long  as  there  is  splenic 
enlargement. f 

Dr.  E.  L.  Moss,  staff-surgeon  in  the  British  Navy,  has  constantly 
found,  after  the  lapse  of  forty-eight  or  more  hours,  organisms  in  the 
blood  of  intermittent  fever  which  he  was  unable  to  find  in  fresh  blood. 
The  organisms  consist  of  bacteria,  singly  or  in  pairs,  in  active  move- 
ment, sometimes  stationary  in  zooglea  groups,  occasionally  in  chains  of 
four  or  more.  Dr.  Moss's  method  would  appear  to  exclude  every 
possibility  of  infection.  His  apparatus  consists  of  a  series  of  small 
glass  bulbs  connected  by  capillary  tubes,  so  that  one  bulb  and  its  contents 

*See  an  article  on  "Infantile  Malarial  Toxaemia,"  by  Dr.  Joel  C.  Hall,  in  the 
Medical  and  Surgical  Reporter,  Vol.  xxxi,  p.  147. 

f  Archives  de  Physiologic,  October,  1876. 


FEVERS.  43 

can  be  separated  from  the  balance  by  the  blowpipe.  The  tubes  and 
bulbs  are  so  arranged  that  the  entire  apparatus  can  be  heated  in  a  water 
or  paraffin  bath.  One  end  of  the  series  is  left  open,  packed  with  baked 
wool  and  connected  with  an  aspirator;  the  other  end  is  drawn  to  a  fine 
point  and  sealed.  The  sealed  point  is  connected  with  a  fine  hypodermic 
needle  by  a  piece  of  rubber  tubing ;  the  needle  is  protected  by  a  glass 
sheath.  The  apparatus  is  repeatedly  heated  in  a  water  bath  before 
using.  To  use  the  apparatus  the  sheath  is  removed  from  the  needle  and 
the  latter  is  plunged  into  aoy  suitable  vein,  the  sealed  point  inside  the 
rubber  connection  is  broken  and  the  blood  flows  gently  through  the 
bulbs,  drawn  on  by  the  aspirator.  When  sufficient  blood  has  entered, 
the  tube  next  to  the  needle  is  instantly  closed  by  the  blowpipe,  and  then 
the  end  near  the  wool  plug. 

CEREBROSPINAL  FEVER  (EPIDEMIC  MENINGITIS, 
OR  SPOTTED  FEVER). 

The  onset  of  this  disease  is  usually  sudden,  often  beginning  with  a 
chill,  vomiting  and  intense  headache,  and  an  elevation  of  pulse  and 
temperature.  The  pathognomonic  symptom  is  that  the  head  is  drawn 
backward  and  downward,  and  the  muscles  at  the  bach  of  the  neck  are 
rigidly  contracted,  and  very  painful  on  motion.  The  pupils  are  also 
contracted. 

At  an  early  period  herpes  may  appear  on  the  face  or  limbs,  the  skin  is 
hypersesthetic,  and  the  patient  cannot  bear  handling.  After  about 
four  days  convulsions  may  set  in,  or  tetanic  contractions  make  their 
appearance,  and  stupor  follows,  passing  into  a  coma,  preceding  dissolu- 
tion. The  bowels  are  persistently  constipated,  and  the  urine  passes 
involuntarily. 

In  cases  tending  toward  recovery  the  acute  symptoms  gradually  subside, 
and,  after  a  week  or  two,  convalescence  takes  place,  attended  by  more  or 
less  headache  and  muscular  contraction. 

In  regard  to  differential  diagnosis,  it  may  be  simulated  by  typhus  or 
masked  variola.  The  absence  of  tetanic  spasms  of  the  post-cervical 
muscles  in  these  diseases  will  aid  in  recognizing  them.  The  protracted 
cases,  where  this  symptom  is  not  prominent,  may  resemble  typhoid 
fever.     In  both  there  is  an  eruption,  some  similar  cerebral  symptoms, 


44 


DIFFERENTIAL   DIAGNOSIS. 


and  occasionally  intercurrent  diarrhoea.  But  the  invasion  of  cerebro- 
spinal meningitis  is  more  sudden,  the  headache  more  violent,  and 
there  is  vomiting-  and  constipation  ;  while  later  the  spinal  pain,  the 
herpes,  the  tetanic  spasms  and  the  continued  headache,  are  broad 
distinctions. 

True  tetanus  is  distinguished  by  the  absence  of  epidemic  prevalence, 
by  the  clearness  of  the  mental  powers,  and  by  the  history  of  the  case 
pointing  to  some  injury. 

Certain  forms  of  malignant  malarial  fever  counterfeit  cerebro-spinal 
meningitis,  especially  during  convalescence,  when  the  affection  presents 
periodical  intermissions  of  the  febrile  state.  The  points  of  difference 
may  be  summed  up  as  follows  (Hamilton)  : — 


CEREBRO-SPINAL  MENINGITIS. 

Inceptive  chill  not  marked. 

Disease    epidemic,    and      chiefly 
among  children. 

Muscular  spasms  the  rule. 

Bowels  constipated. 

Pulse  and   temperature   do    not 
suffer  rapid  variations. 

Temperature    does   not   undergo 
periodical  changes. 

Face    flushed;     eruption    before 
fourth  day. 

Delirium  and  coma  not  affected 
by  large  doses  of  quinine. 

Increase     of    fibrin    and    rapid 
coagulation  of  blood  when  drawn. 


CONGESTIVE  PERNICIOUS  MA- 
LARIAL FEVER. 

Chill  quite  marked. 

Epidemic  and  common  to  all  ages. 

Muscular  spasms  very  rare. 

Not  usually  so. 

Both  subject  to  great  variations, 
feeble  and  irregular. 

Undergoes     decided     periodical 
changes. 

Complexion  sallow;  no  eruption. 

All   symptoms  modified  usually 
by  large  doses  of  quinine. 


In  distinguishing  it  from  other  head  affections  it  should  be  observed 
that,  while  pain  in  the  head,  vomiting,  epileptiform  attacks,  disease 
of  the  optic  discs,  emaciation,  eruptions,  involuntary  micturition, 
are  symptoms  found  in  many  of  them,  the  sudden  onset  of  symptoms, 
pain  in  the  back  of  the  neck,  the  stiffness  of  the  muscles  of  the  neck, 
and   retraction  of    the  head,  are  sufficient   to   separate   cerebro-spinal 


FEVERS. 


45 


meningitis  from  hydrocephalus  acquisitus,  basilar  meningitis,  and  tumor 
of  the  brain,  diseases  to  which,  in  its  symptoms,  it  is  nearly  allied. 

It  may  also  be  noted  that  Dr.  Hayden,  of  Dublin,  a  competent  au- 
thority, states  that  he  never  saw  a  case  of  cerebro-spinal  meningitis 
unattended  by  pains  in  the  calves  of  the  legs,  and  he  should  make  a  pre- 
sumptive diagnosis  from  the  presence  of  that  symptom  alone. 

Dr.  Dowse,  of  London,  has  insisted  on  the  importance  of  distinguish- 
ing sporadic  from  epidemic  cerebro-spinal  meningitis.  He  maintains  that 
in  its  epidemic  form  the  sensorium  is  more  or  less  affected  from  the  first, 
and  that  the  membranes  over  the  superior  cerebral  convolutions,  cerebel- 
lum, and  posterior  columns  of  the  cord,  including  the  nerve  substance, 
are  primarily,  if  not  wholly,  the  seats  of  lesion.  In  the  sporadic  form, 
on  the  contrary,  the  sensorium  and  special  senses  are  only  slightly  influ- 
enced, and  the  inflammation  centres  itself  upon  the  meninges  at  the  base 
of  the  brain  and  the  anterior  columns  of  the  cord.  He  therefore  gives 
to  the  latter  affection  the  name  of  occipito,  or  basic  cerebro-spinal  menin- 
gitis, in  contradistinction  to  the  former  well-known  disease.  He  draws 
his  conclusions  and  diagnosis  from  signs  and  symptoms,  as  evidenced  in 
the  following;  table : — 


EPIDEMIC  CEREBRO-SPINAL 
MENINGITIS. 

Attack  sudden,  without  any  spe- 
cial predisposing  cause. 

Apparently  of  a  contagious  or  in- 
fectious origin. 

Sensorium  affected  from  the  first. 


Excito-motor  spasms  of  a  tonic 
character  in  groups  or  groupings  of 
muscles,  with  marked  loss  of  cutane- 
ous and  muscular  sense. 

Reflex  movements  common. 

Vomiting  urgent  and  uncontrol- 
lable. 

Temperature  rarely  exceeds  100°. 


SPORADIC  OR  BASIC  CEREBRO- 
SPINAL MENINGITIS. 

Attack  commences  gradually  and 
resembles  an  onset  of  acute  rheuma- 
tism. 

Usually  arises  from  exposure  to 
cold,  exhaustion,  and  privation. 

Sensorium  never  affected  until  the 
last  stage. 

Incoordination  of  movement  with 
cutaneous  formication,  partial  anaes- 
thesia, muscular  hyperalgia,  but  no 
tetanic  spasms. 

Reflex  movements  rare. 

Vomiting  not  so  severe. 

Temperature  often  rises  to  105°. 


46 


DIFFERENTIAL    DIAGNOSIS. 


EPIDEMIC  CEREBROSPINAL 
MENINGITIS. 

Purpuric  maculae  diffuse  and  gen- 
eral. 

Death  usually  takes  place  from 
coma. 

Prognosis  grave. 

Post-mortem  appearances  reveal 
the  membranes  over  the  superior 
cerebral  convolutions  and  posterior 
columns  of  the  cord  as  the  seat  of 
lesion. 


SPORADIC  OR  BASIC  CEREBRO- 
SPINAL MENINGITIS. 

Maculae  never  seen  in  the  desu- 
date  form. 

Death  usually  takes  place  from 
apneea. 

Prognosis  hopeful. 

Post-mortem  appearances  reveal 
the  membranes  over  the  base  of  the 
brain  and  over  the  anterior  columns 
of  the  cord  as  the  prime  seat  of 
lesion. 


This  distinction  has,  however,  not  been  wholly  accepted  by  American 
authorities.  Dr.  Da  Costa  questions  the  main  point  of  difference — the 
temperature;  and  Dr.  Alfred  Stille1  writes:  "The  whole  medical 
literature  does  not  contain  a  single  case  of  sporadic  idiopathic  cerebro- 
spinal meningitis  with  the  characteristic  sudden  onset  of  the  epidemic 
disease."  From  that  writer's  admirable  monograph*  we  extract  the  fol- 
lowing exhaustive  comparison  of  meningitis  and  typhus,  with  which  latter 
it  has  often  been  confounded : 


EPIDEMIC  CEREBRO-SPINAL 
MENINGITIS. 

A  pandemic  disease;  occurs  in 
places  remote  from  one  another  and 
without  intercommunication. 

Attacks  all  classes  of  society.  Is 
never  primarily  developed  by  squa- 
lor and  deficient  ventilation. 

Is  not  contagious. 

More  males  than  females  attacked. 

More  young  persons  than  adults 
attacked. 

Generally  occurs  in  winter. 


TYPHUS  FEVER. 

Essentially  an  endemic  disease. 
Always  due  to  local  causes.  Spreads 
by  intercommunication  only. 

Attacks  primarily  the  poor,  filthy 
and  crowded  alone. 

Contagious  in  a  high  degree. 
The  two  sexes  equally  affected. 
More  adults  than  young  persons. 

Epidemics  irrespective  of  season. 


*  "Epidemic  Meningitis,"  pp.  107,  117. 


FEVERS. 


47 


MENINGITIS. 

Eruptions  are  wanting  in  at  least 
half  the  cases ;  they  occur  within 
the  first  day  or  two. 

The  eruptions  are  very  various, 
including  erythema,  roseola,  urti- 
caria, herpes,  etc.  Ecchymoses  are 
common. 

Headache  acute,  agonizing,  ten- 
sive. 

Delirium  often  absent ;  often  hys- 
terical, sometimes  vivacious,  some- 
times maniacal.  Generally  begins 
on  the  first  or  second  day. 

Pulse  very  often  not  above  the 
natural  standard ;  often  preternatu- 
rally  frequent  or  unfrequent.  Is 
subject  to  sudden  and  great  varia- 
tions. 

The  temperature  is  lower  than 
that  recorded  in  any  other  typhoid 
or  inflammatory  disease.  It  is  also 
very  fluctuating. 

The  body  emits  no  peculiar  smell. 

The  tongue  is  generally  moist 
and  soft ;  sordes  of  the  teeth,  etc., 
is  rare. 

Vomiting,  generally  of  bilious 
matter,  is  an  almost  constant  and 
urgent  symptom,  especially  in  the 
first  stage. 

Pains  in  the  spine  and  limbs  of  a 
sharp  and  lancinating  character  are 
usual,  and  evidently  neuralgic. 

Tetanic  spasms  in  a  very  large 
proportion  of  cases,  and  within  the 
first  two  or  three  days. 


TYPHUS. 

The  eruption  is  rarely  absent,  and 
appears  between  the  fourth  and  the 
seventh  day. 

The  eruption  is  uniformly  roseo- 
lous,  and  then  petechial.  Ecchy- 
moses are  rare. 

Headache  dull  and  heavy. 

Rarely  absent;  usually  mutter- 
ing. Rarely  begins  before  the  end 
of  the  first  week. 

A  slow  pulse  exceedingly  rare ; 
its  rate  pretty  constantly  between 
90°  and  120°. 


The  temperature  is  always  more 
or  less  elevated,  and  it  does  not  fall 
until  the  close  of  the  disease.  The 
skin  is  hot,  burning,  and  pungent 
to  the  touch. 

The  mouse-like  odor  of  typhus  is 
characteristic. 

The  tongue  is  generally  dry,  hard 
and  brown,  and  the  teeth  and  gums 
fuliginous. 

Vomiting  is  rare  and  not  urgent. 


Pains  are  dull,  heavy,  and  appar- 
ently muscular. 

Tetanic  spasms  are  unknown  in 
typhus.  Convulsions  sometimes  oc- 
cur, due  to  pyaemia. 


48 


DIFFERENTIAL   DIAGNOSIS. 


MENINGITIS. 

Cutaneous  hypersesthesia  a  promi- 
nent symptom. 

Strabismus  common.  The  eye, 
if  injected,  has  a  light  red  or  pink- 
ish color.  The  pupils  are  often 
unequal. 

Deafness  is  often  complete  and 
permanent. 

Duration  very  indefinite ;  but 
generally  from  four  to  seven  days. 

The  blood  is  often  highly  fibrin- 
ous. 

The  lesions,  unless  in  the  most 
rapid  cases,  consist  of  a  fibrinous  or 
purulent  exudation  in  the  meshes 
of  the  cerebro-spinal  pia  mater. 

Mortality  from  20  to  75  per  cent. 


TYPHUS. 

The  sensibility  of  the  skin  is 
generally  blunted. 

Strabismus  rare.  The  blood  in 
the  conjunctival  vessels  has  a  dark 
hue ;  the  pupils  are  always  equal. 

Deafness  is  hardly  ever  perma- 
nent, or  attended  with  signs  of  dis- 
organization of  the  ear. 

Duration  from  twelve  to  fourteen 
days. 

Blood  never  fibrinous. 

There  are  no  inflammatory  lesions 
whatever. 


Mortality  from  8  to  40  per  cent. 


ACUTE  TUBERCULAR  (GRANULAR)  MENINGITIS. 

This  serious  disease  is  apt  to  be  confounded,  especially  in  the  adult, 
with  typhoid  or  typhus  fever,  the  exanthemata  and  pneumonia.  The 
following  characteristics  of  the  disease,  as  given  by  Drs.  Reginald 
South  ey  and  Hamilton,  will  serve  to  distinguish  it : — 

1.  The  prodromal  symptoms  of  this  form  of  meningitis  are  well 
marked.  The  history  of  the  case  usually  records  an  illness  that  has 
endured  some  two  or  four  weeks,  but  one  which  has  not  attracted  much 
attention  until  distracting  headache,  with  some  delirium  at  night,  has 
supervened. 

2.  Vomiting  is  generally  the  first  and  most  important  symptom. 
Headache  is  invariably  present. 

?>.  After  two  or  three  days  there  is  a  marked  rise  of  temperature,  say 
from  101°  to  105°,  with  greatly  increased  pulse. 

4.  The  bowels  are  constipated  and  not  tender  to  firm  pressure.  Very 
little  nourishment  is  voluntarily  taken.  The  abdomen  becomes  retracted, 
and  the  aspect  of  the  patient,  with  half-open  eyelids,  or  some  slight 
paralysis  of  these,  becomes  highly  diagnostic. 


FEVERS.  49 

5.  There  is  no  characteristic  rash.  The  so-called  tdche  cerebrate  of 
this  form  of  meningitis  is  not  a  true  eruption,  but  is  produced  by  pres- 
sure or  contact.  When  the  finger  is  drawn  across  the  skin  of  the  fore- 
head it  leaves  a  vivid  red  mark,  which  has  been  considered  a  pathogno- 
monic sign  of  the  disease. 

6.  The  skin  is  hypersesthetic,  the  delirium  slight  and  transitory,  the 
temper  irritable,  obstinate  and  unaccommodating. 

7.  There  are  general  muscular  pains,  followed  first  by  stiffness,  and 
then  by  slight  paralysis,  as  shown  in  the  imperfect  coordination  of  the 
muscular  movements,  in  tremblings  and  in  twitchings.  The  muscular 
pain  and  stiffness  are  often  first  complained  of  in  the  nape  of  the  neck, 
and  then  in  the  muscles  of  the  back. 

8.  Slight  epileptiform  convulsions  are  observed,  followed  by  paralysis 
of  motion  in  the  limbs  or  parts  convulsed ;  this  paralysis  being  most 
usually  of  a  transitory  or  temporary  kind.  Among  the  paralyses  most 
characteristic  are  those  affecting  the  optic  commissure  and  oculo-motor 
tracts,  causing  a  slight  internal  squint,  with  dilated  inactive  pupil  of  one 
eye,  with  drooping  of  the  same  eyelid,  and  paralysis  of  the  facial  nerve 
upon  one  side.  The  paralysis  of  the  limbs,  although  usually  hemiplegic, 
is  seldom  one  that  invades  the  body  upon  one  side  in  its  entirety. 
Further,  its  mode  of  attack  is  gradual ;  usually,  the  arm  and  leg  are 
affected  upon  the  same  side,  even  when  the  facial  muscles  are  not  involved. 

YELLOW  FEVER. 

The  name  Yellow  Fever  is  misleading,  as  the  coloration  of  the  skin  to 
which  it  refers  is  not  an  invariable  nor  even  a  common  sign  of  the  dis- 
ease. According  to  Dr.  Greensville  Dowell,*  the  skin  does  not  turn 
yellow  in  more  than  one  case  in  six,  and  many  die  before  there  is  the  least 
appearance  of  yellowness  even  in  the  eyes.  Of  those  who  die  after  the 
black  vomit  has  set  in,  not  more  than  one  in  three  presents  the  yellowness. 

The  pathognomonic  sign  of  the  disease  is  the  black  vomit.  It  is 
brownish  black,  semi-fluid,  with  a  glistening  reflection  and  acid  reaction, 
and  varies  in  quantity  from  a  mere  stain  on  a  handkerchief  to  many 
pints  in  the  twenty-four  hours.  It,  however,  is  not  thrown  up  in  more 
than  one  in  three  fatal  cases. 

*  "Yellow  Fever  and  Malarial  Diseases." 


50  DIFFERENTIAL   DIAGNOSIS. 

The  usual  course  of  the  disease  as  witnessed  in  the  southern  and  south- 
western States  is  as  follows: — 

1.  Onset  with  a  chilly  feeling  along  the  spine,  passing  into  actual  rigor. 

2.  Pain  in  the  head,  severe  in  proportion  to  the  malignancy  of  the 
disease. 

3.  Fever  slight,  tending  to  perspiration. 

4.  Remission  after  a  period  varying  from  twenty-four  hours  to  five 
days. 

5.  The  secondary  fever,  commencing  usually  without  a  chill ;  it  runs 
an  indefinite  course. 

The  discoloration  begins  at  the  white  of  the  eye,  and  extends  over  the 
skin  of  the  forehead,  chest,  abdomen,  and  extremities.  The  urine  is  high- 
colored  and  stains  linen,  and  in  some  cases  the  perspiration  gives  the 
same  yellowish  stain. 

The  shades  which  separate  the  symptoms  of  one  fever  from  those  of 
another,  in  warm  climates,  are  sometimes  of  such  gentle  gradation  that 
prime!  facie  they  may  seem  to  belong  to  one  and  the  same  disease;  this 
more  especially  refers  to  the  yellow  and  remittent  type  of  fevers,  between 
which  so  slight  is  sometimes  the  distinction,  that  bilious  remittent  has 
frequently  been  considered  and  classified  as  true  yellow  fever;  for  in  the 
prominent  symptoms  which  appear  in  both  yellow  and  remittent  fever  a 
great  similarity  obtains;  both  take  their  origin  in  paludal  soils;  both  in 
their  course  offer  symptoms  of  so  seemingly  similar  a  nature  that  the 
shades  of  difference  are  so  slight  as  to  frequently  escape  even  a  good 
observer  and  cause  him  to  fall  into  error.  But  this  apparent  similarity 
vanishes  on  close  and  continuous  inspection,  for  then  essential  and  dis- 
tinctive marks  are  observed,  which  stamp  each  with  an  individuality,  and 
which  characterize  each  as  a  separate  disease,  distinct  in  its  essence  and 
differing  signally  the  one  from  the  other.  These  differences  may  be 
summarized  as  follows  (J.  J.  L.  Donnet,  DaCosta,  Dowell,  and  others) : 
YELLOW  FEVER.  BILIOUS  REMITTENT. 


Is  essentially  of  an  infectious  na- 
ture, and  found  in  cities. 

Chiefly  vigorous  and  young  con- 
stitutions fall  victims  to  it.    Colored 


Is   not  of  an    infectious  nature, 
and  usually  found  in  the  country. 

All   ages   and   constitutions    are 
liable,    and    the   weakest    most   so. 


population  less  liable  than  white.      |  Colored  population  liable. 


FEVERS. 


51 


YELLOW  FEVER. 

Restricted  chiefly  to  the  yellow 
fever  zone. 

Is  of  a  continued  type;  remis- 
sions not  marked. 

Temperature  in  bad  cases  very 
high. 

Usually  attacks  at  night. 

Severe  nausea  and  vomiting 
throughout.  Epigastric  tenderness 
early  and  decided  black  vomit. 
Headache  occipital. 

Hemorrhages  from  the  gums  and 
various  parts  of  the  body. 

Tongue  clean  or  but  slightly 
coated;  pulse  variable,  becoming 
slow  in  the  last  stages. 

Eye  highly  injected  and  humid  ; 
expression  often  fierce  or  anxious. 

Pain  in  the  back  very  severe ; 
also  pain  in  the  calves  and  over  the 
eyes. 

Delirium  rare;  mind  generally 
clear  and  cheerful. 

Urine  generally  albuminous;  sup- 
pression common. 

Muscular  prostration  slight ;  con- 
valescence rapid ;  no  sequelae. 

Liver  aifected  and  slightly  en- 
larged. 

Spleen  not  aifected. 

One  attack  affords  an  almost  cer- 
tain immunity. 

Mortality  very  high. 

Peculiar  smell  often  perceptible. 


BILIOUS  REMITTENT. 

Is  to  be  found  in  all  parts  of  the 
world  where  marshy  soils  prevail. 

Remissions  observed  in  the  morn- 
ing. 

Temperature  not  extraordinarily 
high. 

Usually  attacks  in  daytime. 

Nausea  and  vomiting  moderate. 
Epigastric  tenderness  slight.  Head- 
ache frontal. 

No  hemorrhagic  tendency. 

Tongue  heavily  coated ;  pulse 
varies  little,  remaining  quick  until 
convalescence  sets  in. 

Eye  and  physiognomy  not  pe- 
culiar. 

Rachialgia  slight  or  absent ;  head- 
ache moderate. 


Delirium  frequent;  mind  always 
dull. 


sup- 


Albuminous    urine    rare 
pression  also  rare. 

Much  muscular  prostration  ;  con- 
valescence slow;  sequela?  various 
and  tedious. 

Liver  not  affected. 

Spleen  invariably  affected. 

One  attack  seems  rather  to  pre- 
dispose to  others. 

Mortality  slight. 

No  peculiar  smell  observed. 


O'J 


DIFFERENTIAL   DIAGNOSIS. 


YELLOW  FEVER. 

Never  merges  into  intermittent. 

Treatment    unsatisfactory ;    qui- 
nine useless. 


Autopsies  show  great  congestion, 
inflammation,  ulceration  and  soften- 
ing of  the  stomach.  Liver  en- 
larged, fatty,  yellowish  in  color,  its 
secreting  cells  filled  with  oil  glob- 
ules. Heart  often  exhibits  disinte- 
gration of  the  muscular  fibres. 


BILIOUS  REMITTENT. 

Often  merges  into  intermittent. 

Quite  amenable  to  treatment ;  an- 
tagonistic power  of  quinine  beyond 
question. 

Autopsies  show  congestion  of  the 
stomach,  but  rarely  inflammation. 
Liver  of  an  olive  or  bronze  hue, 
not  fatty.     Spleen  enlarged. 


RELAPSING  FEVER. 

Of  late  years  epidemics  of  this  disease  have  appeared  at  various  points 
in  this  country.  It  is  eminently  contagious  in  character,  and  a  physician 
should  be  prepared  to  recognize  it  early.  The  invasion  is  sudden,  the 
fever  soon  developed  and  high,  the  pulse  very  rapid,  the  skin  often 
jaundiced,  and  the  temperature  elevated  (106°-107°).  Toward  the  close 
of  the  first  week  the  symptoms  rapidly  subside,  and  convalescence  seems 
at  hand ;  but  after  about  another  week  the  symptoms  all  return  with  as 
much  violence  as  ever,  to  again  disappear,  as  a  rule,  after  four  or  five  days. 

The  epidemic  prevalence  of  the  disease,  its  sudden  invasion,  the  per- 
sistence without  remission  of  the  high  febrile  symptoms,  and  the  a-febrile 
interval,  give  it  a  peculiar  physiognomy. 

The  characteristic  feature  of  the  disease,  asserted  by  some  to  be  truly 
pathognomonic,  is  the  presence  of  spirillium  in  the  blood.  The  following 
method  of  demonstrating  them  is  that  recommended  by  Dr.  R. 
Albrecht,  of  St.  Petersburg  :* — 

Spread  out  a  drop  of  blood  on  a  slide,  not  too  thin  ;  let  it  dry;  treat 
it  with  a  drop  of  acetic  acid,  and  repeat  it  in  a  few  seconds.  By  this 
means  all  the  fibrin  and  blood-corpuscles  will  be  destroyed  and  dissolved, 
and  after  careful  washing  away  of  the  acid  with  distilled  water,  and  final 
drying,  the  preparation  is  ready  for  use.  With  a  little  care  in  washing, 
which  must  not  be  in  a  stream,  the  spirilla  are  not  lost,  especially  if  the 
preparation  has  been  dried  for  six  to  twelve  hours  before  being  treated 
*  St.  Petersburg  Med.  Wochenschrift,  June,  1878. 


FEVERS. 


53 


with  acetic  acid.  The  glass  slide  then  looks  quite  transparent,  and,  at 
the  place  where  the  drop  of  blood  was,  it  looks  a  little  dusty.  Under 
the  microscope  the  nuclei  and  nucleoli  of  the  white  blood  corpuscles  are 
visible,  and  between  these  the  spirilla  lie  in  great  numbers  and  in  the 
most  distinct  arrangement  and  position,  showing  up  very  beautifully  and 
distinctly.  They  give  the  impression  of  being  thicker  than  they  gener- 
ally are,  probably  because  they  are  no  longer  imbedded  in  a  highly  re- 
fracting substance — plasma. 

Relapsing  fever  is  liable  to  be  mistaken  for  one  of  the  forms  of  con- 
tinued fever.  Its  epidemic  prevalence  will  naturally  put  the  physician 
on  his  guard.  It  is,  moreover,  especially  a  disease  of  the  lower  classes, 
who  suffer  from  insufficient  food  and  filthy  surroundings.  In  most  cases 
it  is  associated  with  jaundice,  which  is  a  rare  complication  in  typhoid. 
When  the  disease  rapidly  abates,  and  this  cessation  is  followed  by  the 
characteristic  relapse,  no  reasonable  doubt  as  to  its  nature  can  be  enter- 
tained. The  main  distinctions  between  relapsing  and  typhoid  may  be 
thrown  into  a  comparative  view  as  follows  : — 


RELAPSING  FEVER. 
Invasion  sudden. 

Bowels  generally  constipated 
Conjunctivitis. 

Liver  engorged,  skin  yellow,  ten- 
derness over  epigastrium. 

Temperature  high,  105°-107°. 

Fever  abates  in  three  or  four  days, 
with  critical  sweats ;  diminution  or 
cessation  of  the  febrile  symptoms, 
with  subsequent  relapse. 

Spirilla  in  the  blood. 
Splenic  enlargement. 
No  characteristic  eruption. 


TYPHOID  FEVER. 

Invasion  gradual,  with  epistaxis ; 
no  chill. 

Generally  diarrhoea. 

No  conjunctivitis;  eyes  bright  and 
clear. 

No  yellowness;  tenderness  over 
right  iliac  region. 

Temperature  during  first  week 
rarely  above  104°. 

These  phenomena  absent ;  symp- 
toms continuous  for  three  or  four 
weeks. 

No  spirilla. 

Spleen  not  materially  enlarged. 

"  Hose  spots,"  inflammation  of 
Peyer's  glands. 


54  DIFFERENTIAL  DIAGNOSIS. 


CHAPTER  II. 

DISEASES  OF  THE  BLOOD. 

Contents. —  The  Dyscrasia — The  Arthritic,  Dartrous,  or  Rheumic  Dys- 
crasia— The  Scrofulous  or  Strumous  Dyscrasia — The  Syphilitic  Dys- 
crasia — The  Tuberculous  Dyscrasia — Rheumatism — Chronic  Rheuma- 
tism—  Gout — Rheumatic  Arthritis — Pernicious  Anosmia  and  Leukemia. 

THE  DYSCRASIA. 

As  is  justly  remarked  by  Professor  Theodor  Billroth,  in  his  Sur- 
gical Pathology,  while  it  is  true  that  there  are  some  objections  to  the 
employment  of  the  term  dyscrasia,  as  committing  one  to  a  humoral 
pathology,  these  are  overbalanced  by  the  fact  that  there  are  certain  well- 
defined,  long-recognized,  inherited  physical  peculiarities,  which  render 
the  person  possessing  them  unusually  prone  to  certain  diseases  and 
complications,  and  which  lend  a  complexion  of  their  own  to  very  many 
affections  seemingly  remote  in  form  and  pathology. 

These  constitutional  tendencies  may  as  well  be  known  by  the  term 
Dyscrasice  as  by  any  other,  since  their  existence  cannot  well  be  denied. 

The  principal  dyscrasise  are :  1.  The  arthritic,  sometimes  called  dar- 
trous or  rheumic,  believed  to  be  pathologically  akin  to  gout  and  rheuma- 
tism ;  2.  The  strumous,  or  scrofulous ;  3.  The  syphilitic ;  and  4.  The 
tuberculous,  or  phthisical ;  the  last  three  mentioned,  in  the  opinion  of 
some,  being  derived  from  a  common  ancestral  taint. 

I.    THE  ARTHRITIC,  DARTROUS,  OR   RHEUMIC 
DYSCRASIA. 

This  form  of  blood  poisoning  has  been  aptly  termed,  by  Mr.  Jonathan 
Hutchinson,  "  the  basis-diathesis  on  which  both  gout  and  rheumatic 
arthritis  are  built,  and  which  to  a  large  extent  is  indifferent  and  common 
to  both."  When  a  man  with  such  a  diathesis  becomes  affected  with  a 
renal  disease,  gout  develops    itself;   otherwise  he    will  probably  have 


DISEASES   OF   THE   BLOOD.  55 

rheumatism.  In  many  families  it  is  observed  that  the  males  have  gout, 
the  females  rheumatism.  The  explanation  is  not  far  to  seek.*  In 
another  lecture  Mr.  Hutchinson  describes  gout  as  "chronic  rheumatism 
plus  a  dietetic  derangement." 

Many  skin  diseases,  nervous  affections  (so-called),  "cramp  colic,"  head- 
aches, sciatica,  vertigoes,  palpitation,  and  obstinate  dyspepsia  are  really 
latent  gout.  In  such  cases  there  is  usually  a  history  of  antecedent  or 
hereditary  rheumic  diathesis,  frequent  acid  eructations,  the  emission  of 
pale,  limpid,  acid  urine,  of  low  specific  gravity,  and  with  traces  of  sugar 
or  albumen  or  both;  some  varicosity  of  the  veins;  the  nails  are  brittle; 
and  there  is  slight  redness  around  the  eye,  indicative  of  mild  chronic  con- 
junctivitis (Dr.  J.  Russell  Reynolds). 

The  following  are  the  signs  as  stated  by  Professor  Hardy,  of  Paris  : 
Persons  who  have  this  diathesis  appear  to  enjoy  good  health,  but  their 
skin  is  habitually  dry  and  their  perspiration  scanty.  They  often  expe- 
rience a  lively  itching  without  eruption.  The  appetite  is  generally  well 
developed,  and  they  are  apt  to  eat  a  much  greater  quantity  of  food 
(especially  animal  food)  than  others  in  analogous  conditions.  Another 
important  peculiarity  is  the  extreme  sensibility  of  the  skin  and  the 
facility  with  which  it  is  influenced  by  the  lightest  and  most  fugitive 
impressions.  Sometimes  general  excitement,  alcoholic  excess,  watching, 
use  of  coffee,  of  certain  kinds  of  food;  sometimes  a  local  excitement, 
irritating  frictions,  or  the  application  of  a  plaster,  will  give  rise  to  an 
eruption,  often  ephemeral,  which  reveals  a  peculiar  predisposition  of  the 
economy,  and  the  existence  of  a  latent  vice  which  needs  but  a  favorable 
occasion  to  manifest  itself. 

To  this  diathesis  Hardy  ascribes  eczema,  lichen,  psoriasis  and  pityri- 
asis, among  diseases  of  the  skin.f 

Mr.  Prescott  Hewett  adds  that  when  a  patient  complains  of  dys- 
pepsia, more  or  less  troublesome,  frequent  deposits  of  lithates  in  the 
urine,  slight  eczematous  eruptions  on  the  skin  from  time  to  time,  anoma- 
lous wandering  pains  in  various  muscles,  sharp,  deep-seated  pains  in  the 
tongue,  continuing  for  two  or  three  days,  and  then  disappearing  alto- 
gether for  a  while,  crackling  about  the  cervical  spine  on  slight  niove- 

*  Medical  Times  and  Gazette,  June,  1876. 
f  Maladies  de  la  Peau,  Paris,  1860. 


56  DIFFERENTIAL   DIAGNOSIS. 

ments,  some,  it  may  be  very  slight,  knottiness  about  the  smaller  joints 
of  the  fingers — we  mavbe  very  certain  that  he  has  the  arthritic  diathesis. 

Sir  James  Paget  adds  to  the  above:  Small  (chalky)  nodules  in  the 
cartilages  of  the  ears  (tophi);  nodular  enlargement  of  the  knuckles; 
thickening  of  the  cutis,  with  subcutaneous  bursee  over  the  knuckles, 
chiefly  between  the  first  and  second  phalanges  of  the  fingers ;  thickening 
of  the  palmar  fascia,  adhering  to  the  cutis,  and  producing  contraction  of 
the  fingers ;  spontaneous  pain  in  the  tendo-Achillis ;  pain  in  the  heel ; 
frequent  and  persistent  erections  at  night,  not  connected  with  any  sexual 
feelings;  "burning  soles"  and  "burning  palms;"  sensations  of  heat;  ting- 
ling and  burning  patches  of  the  skin  of  the  thighs,  without  external  ap- 
pearances of  redness  or  eruption;  patches  of  "dry  eczema." 

In  such  patients,  an  injury  may  be  followed  by  a  well-marked  attack 
of  gout ;  or  the  trouble  may  linger,  with  pain  and  occasional  swelling, 
and  with  constantly  increasing  distrust  of  surgery  and  the  surgeon,  till 
some  one  suspects  the  existing  taint  of  the  arthritic  diathesis,  and  acting 
on  the  suspicion,  addresses  his  remedies  to .  it,  and  promptly  cures  the 
local  trouble. 

(The  points  of  diagnosis  between  the  gouty  diathesis  and  chronic 
rheumatism,  as  summed  up  by  Fothergill,  are  given  on  page  64,  in 
the  section  devoted  to  "  Diseases  Likely  to  be  Confounded  with  Rheuma- 
tism.") 

II.  THE  SCROFULOUS  OR  STRUMOUS  DYSCRASIA. 

Sir  James  Paget  defines  the  principal  signs  of  scrofulous  constitution 
to  be  slowly  progressive  and  long  abiding  inflammation,  provoked  by 
less  causes  than  would  excite  inflammation  in  healthy  persons,  the  inflam- 
matory process  tending  to  the  production  of  "  cheesy  "  matter ;  the  middle 
permanent  incisors,  with  their  borders  barred,  crenated,  thin  and  brittle; 
the  mucous  membrane  of  the  lower  turbinated  bone  swollen,  puffed  and 
congested ;  a  long  abiding  ozsena  in  early  life,  with  frequent  or  daily 
discharge  of  scabs ;  general  swelling,  with  glandular  enlargement  of  the 
whole  naso-palatine  mucous  membrane;  a  granular  pharynx,  with  its 
lining  membrane  more  or  less  thickly  scattered  with  prominent  glands ; 
the  perforating  ulcer  of  the  nasal  septum — these  are  some  of  the  minor 
signs.     Still  more  positive  are  enlarged  and  suppurating  lymph  glands 


DISEASES   OF   THE   BLOOD.  57 

discharging  curdy  pus,  and  slowly  healing  with  red-banded  and  barred 
scars;  pustules  by  the  edge  of  the  cornea;  frequent  impetigo  with  swollen 
glands;  periosteal  swellings  of  the  phalanges;  chronic  thickenings  of 
synovial  membranes ;  obstinate  otorrhoea.  If  a  patient  is  found  to  have 
or  to  have  had  any  few  of  these,  he  may  justly  be  pronounced  scrofulous, 
and  scrofula  may  be  suspected  in  any  localized  morbid  process  in  hirn. 
Or,  if  these  diseases  are  known  to  have  occurred  singly  or  together  in 
many  members  of  a  family,  we  should  look  out  for  scrofula  as  an  element 
of  whatever  disease  may  appear  in  any  member  of  that  family. 

Dr.  Francis  Delafield,  of  New  York  city,  observes*  that  practi- 
tioners in  this  country  see  comparatively  so  little  of  scrofula  that  it  is 
difficult  for  them  to  appreciate  the  prominent  place  it  holds  in  the  minds 
of  physicians  in  European  countries.  It  is  a  condition  which  is  hardly 
susceptible  of  a  definition,  and  yet  it  is  not  hard  to  understand  what  is 
meant  by  the  term. 

It  means  this:  When  an  individual  acquires  an  inflammation  of  a 
mucous  membrane,  of  the  skin,  of  the  joints,  of  the  bones,  of  the  genito- 
urinary apparatus,  or  of  almost  any  part  of  the  body,  such  an  inflam- 
mation usually  runs  an  acute  course  and  terminates  in  resolution,  or  in 
suppuration,  or  in  the  formation  of  organized  new  tissue.  But,  if  the 
inflammation,  instead  of  doing  this,  simply  reaches  a  certain  point  and 
stays  there,  and  then,  instead  of  resolving  or  suppurating  merely,  goes 
through  a  succession  of  degenerative  changes,  such  an  inflammation  is 
said  to  be  scrofulous. 

The  scrofulous  inflammations  have  several  well-marked  characteristics. 
They  are  very  slow  in  their  progress  ;  they  are  very  rebellious  to  treat- 
ment ;  they  are  accompanied  by  an  extensive  cellular  infiltration  of  the 
inflamed  parts,  so  that  when  the  degenerative  changes  ensue  there  is  large 
destruction  of  tissue.  The  degeneration  which  occurs  in  the  products  of 
such  a  scrofulous  inflammation  is  peculiar  in  its  nature ;  it  is  commonly 
called  cheesy  degeneration,  and  consists  in  the  transformation  of  the  pro- 
ducts of  inflammation  into  a  dry,  yellow  mass,  composed  of  amorphous 
granular  matter.  Examples  of  this  form  of  inflammation  will  at  once 
suggest  themselves.  Caries  of  the  vertebra,  hip-joint  disease,  white 
swelling  of  the  knee-joint,  scrofulous  orchitis,  and  enlarged  lymphatic 
glands,  are  all  of  frequent  occurrence. 

*  N.  T.  Medical  Record,  Vol.  x,  p.  338. 


58  DIFFERENTIAL   DIAGNOSIS. 

III.    THE  SYPHILITIC  DYSCRASIA. 

Apart  from  the  special  recognition  of  constitutional  syphilis,  it  is  of 
the  utmost  importance  for  the  physician  to  be  on  the  alert  to  recognize 
and  meet  the  syphilitic  dyscrasia  as  it  exists,  (1)  in  the  infantile  period 
of  life  by  inheritance,  and  (2)  in  advanced  years  developed,  or  in  the 
condition  of  latency. 

Mr.  Jonathan  Hutchinson  (loc.  cit.),  states  that  in  the  infantile 
period  we  recognize  syphilis  by  the  peculiarity  of  certain  single  symp- 
toms, or  else  by  the  peculiar  grouping  of  several  different  symptoms. 

The  rash  on  the  skin  is  one  of  the  commonest  evidences.  It  is  usually 
erythematous  or  papular,  of  a  peculiar  red  or  coppery  tint,  in  abruptly- 
margined  patches.  Pustular,  vesicular  and  bullous  rashes  and  condylo- 
mata about  the  anal  orifice  are  also  frequent. 

The  snuffles,  a  peculiar,  obstinate  coryza,  is  almost  always  present. 

Iritis  and  a  tendency  to  deep-seated  inflammation  of  the  eyes  are  often 
met  with. 

At  or  about  the  age  of  one  year,  if  the  child  survives,  these  symptoms 
usually  all  disappear,  and  the  disease  enters  upon  its  stage  of  latency. 

To  detect  its  presence  in  the  system  at  this  period,  we  must  first  look  to 
the  evidences  of  past  disease. 

A  sunken  bridge  of  nose,  caused  by  the  long  continued  swelling  of  the 
nasal  mucous  membrane  when  the  bones  are  soft;  a  skin  marked  by  little 
pits  and  linear  scars,  especially  near  the  angles  of  the  mouth ;  the  relics 
of  an  ulcerating  eruption  in  early  life;  a  protuberant  forehead  consequent 
upon  infantile  arachnitis ;  clouds  in  the  cornea  from  past  iritis — are  all 
signs  pointing  to  the  constitutional  taint. 

The  teeth  furnish  valuable  aid  in  diagnosis.  The  upper  central  incisors 
are  narrow  and  short,  and  notched  in  the  centre  in  a  half-moon  shape,  a 
shallow  furrow  running  from  this  notch  to  the  gum;  the  canines  are 
narrow,  rounded  and  peg-like ;  there  are  usually  interspaces  between 
the  teeth.     This  may  be  considered  an  almost  absolute  sign  of  the  taint. 

The  general  growth  is  not  often  retarded,  but  the  complexion  is  an 
important  indication.  It  is  exceedingly  rare  to  meet  a  florid,  good  com- 
plexion in  a  young  adult  who  is  the  subject  of  this  taint.  It  is  almost 
always  pale. 

Such  persons,  seemingly  in  full  youth  and  vigor,  generally  have  little 


DISEASES   OF  THE   BLOOD.  59 

spontaneous  physical  energy ;  they  do  not  seek  athletic  exercise  nor  the 
trials  of  strength ;  and  are  languid  in  motion. 

Other  signs  which  may  be  mentioned  are:  a  patch  upon  the  choroid,  an 
optic  irregular  neuritis;  a  faint  interstitial  keratitis;  an  unequal  thicken- 
ing of  the  vocal  cords,  with  cicatrices  of  old  ulceration ;  and  last,  but 
not  least  —  and  especially  where  syphilis  is  associated  with  a  gouty  habit 
of  body — psoriasis  upon  the  sides  of  the  tongue,  as  well  as  an  indurated 
irregular  thickening  of  the  lower  bowel. 

IV.     THE  TUBERCULOUS  DYSCRASIA. 

There  are  families  in  which  the  children,  while  apparently  healthy 
during  their  development,  perish  early  in  adult  life  with  tubercular 
manifestations,  especially  in  the  lungs.  This  indicates  a  peculiar  inherit- 
ance, which  may  be  called  the  tubercular  dyscrasia.  More  frequently 
the  children  of  decidedly  strumous  parents  die  in  infancy,  with  tubercular 
meningitis,  which  furnishes  ground  for  the  belief  that  in  many  instances 
tubercular  disease  is  brought  about  by  the  strumous  dyscrasia;  and,  indeed, 
it  is  by  many  identified  with  it.  The  physical  characteristics  of  scrofu- 
lous subjects  belong  also  to  the  majority  of  consumptives,  in  a  greater  or 
less  degree.  Others  are  predisposed  to  the  disease  through  defective 
oxygenation  caused  by  unfavorable  form  of  the  thoracic  walls.  But  the 
researches  on  this  subject  are  still  incomplete,  and  it  is  well  to  bear  in 
mind  the  words  of  Dr.  A.  T.  H.  Waters  : — 

"There  is  no  temperament  which  does  not  furnish  victims  to  consump- 
tion ;  nor  can  we  say  that  there  is  any  conformation  of  the  body  which 
is  characteristic  of  the  phthisical.  I  have  seen  men  and  women  with  the 
best  developed  frames  and  the  most  ample  chests  attacked  with  phthisis. 
You  must  not,  therefore,  be  misled,  by  the  existence  of  these  conditions, 
by  the  appearance  of  robustness  in  your  patients,  into  imagining  that 
they  cannot  possibly  become  the  subjects  of  this  disease." 

The  diagnosis  of  these  different  conditions  is  made  less  difficult  by 
bearing  in  mind  their  peculiar  tendencies  and  characteristic  manifesta- 
tions, as  set  forth  in  the  table  upon  the  next  page. 


60 


DIFFERENTIAL   DIAGNOSIS. 


SCROFULOSIS. 
More  particularly  limited 
to  childhood. 


Affects  especially  t  h  e 
lymphatic  glands  (causing 
abscess),     the    mucous 

membranes  (ophthalmia), 
the  skin  (obstinate  cutane- 
ous diseases,  especially  the 
pustular)  and  bones  (caries 
and  necrosis,  abscesses  in- 
dolent (cold  abscess).  Fre- 
quently resulting  in  phthisis 
and  hydrocephalus. 


Generally  afebrile. 

Temperament  phlegma- 
tic ;  mind  and  body  back- 
ward :  skin  muddy ;  upper 
lip  thick  ;  nostrils  wide  and 
alas  thickened.  Abdomen 
tumid;  ends  of  bones  large; 
shafts  thick.  Otorrhcea, 
ozaena,  ophthalmia  com- 
mon. 


Mercury  prohibited. 


TUBERCULOSIS. 

Not  specially  limited. 


Affects  internal  organs 
(phthisis,  hydrocephalus, 
peritonitis,  tabes  of  mesen- 
teric, or  bronchial,  glands). 


Pyrexia  marked  in  acute 
cases,  irregular  in  chronic. 

Nervous  system  highly 
developed  ;  mind  and  body 
active ;  organization  deli- 
cate and  refined.  ''  Thin 
skin,  clear  complexion,  the 
surface  veins  distinct,  eyes 
bright,  pupils  large,  eye- 
lashes long,  hair  silken, 
face  oval,  ends  of  bones 
small,  shafts  thin,  limbs 
straight"   (Jexner). 

Mercury  only  for  tempo- 
rary indigestions,  etc.,  used 
carefully. 


INHERITED  SYPHILIS. 

Manifests  itself  early, 
generallybefore  third  month 
(from  fourteen  days  to  six 
weeks). 

Prominent  symptoms : — 
Cachectic  appearance,  snuf- 
fles, condylomata  around 
the  anus.  Child  thin,  poorly 
nourished,  muscles  flabby. 
Skin  brownish,  cracked, 
thick  and  rough.  Fonta- 
nelle  open;  ossification  slow. 
Posterior  cervical  glands  en- 
larged. Second  set  of  incis- 
ors characteristic  ( Hutchin- 
son teeth).  The  central  inci- 
sors short,  narrow  and  thin, 
chisel-shaped  ;  edges  soon 
become  notched  and  bro- 
ken ;  also  striped  or  ribbed 
horizontally.  Hair  thin, 
and  may  have  alopecia. 
Eruptions  copper  -  colored 
and  chronic  ;  generally  dry, 
but  may  be  pustular  (eryr 
thema,  lichen,  psoriasis  and 
eczema,  or  impetigo,  ecthy- 
ma and  pemphigus),  often 
seen  on  palms  of  hands  or 
soles  of  feet.  Liver  en- 
larged (albuminoid).  As- 
cites common,  with  tympa- 
nites. 

Pyrexia  only  in  compli- 
cations. 

Physically  and  mentally 
inferior  in  structure,  and 
slow  in  movement;  inactive, 
dull  and  often  cachectic 
looking. 


choi 


Mercury     the    sheet-an- 


They  resemble  each  other  in  hereditary  character,  their  familiar  mani- 
festations being  readily  induced  by  defective  hygienic  conditions. 


DISEASES   OF   THE   BLOOD.  63 

DISEASES   LIKELY  TO  BE  CONFOUNDED  WITH  RHEU- 
MATISM. 

Ordinarily  an  attack  of  acute  rheumatism  is  recognized  without  diffi- 
culty by  the  pains  in  the  joints,  their  swelling  and  tenderness,  the  shift- 
ing character  of  the  disorder  from  joint  to  joint,  and  the  absence  of  the 
symptoms  so  common  in  continued  fevers,  of  disturbance  of  the  stomach 
and  brain  (if  we  except  the  so-called  cerebral  rheumatism  which  appears 
to  be  associated  with  a  ursemic  condition,  if  its  symptoms  are  not  in 
reality  occasioned  in  this  way),  as  well  as  of  the  intermissions  or  remis- 
sions of  periodic  fevers. 

Nevertheless  it  is  true,  as  remarked  by  Dr.  S.  O.  Habershox,*  that 
while  there  are  many  characteristics  of  true  rheumatic  disease,  few 
maladies  are  more  easily  mistaken,  and  there  is  no  sign  which  is  uni- 
formly present.  Pain  is,  perhaps,  the  most  constant  indication,  with 
stiffness  of  one  or  more  joints;  but  rheumatic  pericarditis  may,  and  often 
does,  exist  without  any  pain  whatever.  The  same  may  be  said  in  refer- 
ence to  febrile  symptoms,  to  increase  of  temperature,  and  to  changes  in 
the  urine ;  none  of  these  signs  is  pathognomonic.  Many  maladies  are 
designated  rheumatic  which  have  no  connection  with  that  disease. 

1.  Diseases  of  the  spine  are  often  said  to  commence  with  an  attack  of 
rheumatism ;  but  it  will  generally  be  found  that  the  pain  in  the  course 
of  the  nerves  or  in  the  fibrous  tissues  arises  from  direct  implication  of 
the  nerves  or  their  centres. 

2.  The  same  remark  applies  to  pain  produced  by  the  pressure  of  can- 
cerous, aneurismal,  or  other  tumors.  Thus  cancerous  disease  of  the  lum- 
bar glands  is  often  mistaken  for  lumbago ;  so  also  the  pain  from  aneurismal 
disease  of  the  thoracic  and  abdominal  aorta,  when  no  pulsating  tumor  can 
be  detected,  is  referred  to  rheumatism. 

3.  During  the  course  of  renal  disease,  abnormal  irritation  arises  not 
only  in  the  serous  membranes,  producing  pericarditis,  pleurisy,  perito- 
nitis, etc.,  but  a  similar  change  happens  with  the  synovial  membranes, 
and  a  form  of  disease  is  induced  which  simulates  rheumatism. 

4.  In  chronic  poisoning  by  lead,  vague  pains  in  the  fasciae,  as  well  as 
in  the  joints,  have  been  designated  "saturnine  arthralgia." 

*  Half-  Yearly  Compendium  of  Medical  Science.    III. 


62  DIFFERENTIAL   DIAGNOSIS. 

5.  Periosteal  disease  is  occasionally  a  source  of  fallacy  in  the  diagnosis 
of  rheumatism. 

6.  Shingles  or  herpes  zoster  may  be  found  in  the  course  both  of  the 
cerebral  and  spinal  nerves;  and  the  severe  pain  which  precedes  the  erup- 
tion of  the  vesicles,  and  which  also  follows  their  disappearance,  closely 
simulates  local  rheumatism. 

7.  A  more  important  disease,  and  one  which  is  attended  with  fatal 
issue,  is  pycemia.  It  closely  resembles  rheumatism ;  for,  with  rigor  and 
febrile  symptoms,  there  is  fixed  pain  and  swelling  in  the  joints — first 
one  and  then  another  being  affected,  though  without  subsidence  of  those 
parts  first  attacked.  But  while  there  may  be  some  similarity  in  the  symp- 
toms, the  prognosis  is  widely  different.  The  one  is  generally  a  curable 
disease ;  the  other  a  fatal  one. 

8.  Acute  synovitis  closely  resembles  rheumatism,  having  pain  and  heat 
in  the  joint,  with  distention.  But  as  a  rule  it  affects  only  one  joint;  it  is 
never  subject  to  metastasis;  and  there  is  little  or  no  effusion  into  the  sur- 
rounding tissue.  The  accumulation  of  fluid  in  the  joint  is  greater,  but 
the  constitutional  symptoms  are  less  prominent. 

9.  Milk  leg  occurs  after  fevers,  or,  in  women  after  confinement.  The 
limb  swells  throughout,  becoming  white,  firm,  hot  and  shining,  and  pits 
but  little  on  pressure.  The  history  of  the  case  and  appearance  of  the 
limb  are  usually  sufficient  to  form  the  diagnosis. 

CHRONIC  RHEUMATISM. 

The  most  common  form  of  chronic  rheumatism  is  that  which  affects 
the  muscles,  and  it  is  frequently  by  no  means  easy  to  distinguish  the 
pains  due  to  the  rheumatic  diathesis  from  those  of  a  wholly  diverse 
etiology. 

The  principal  distinctions  are — 

1.  From  neuralgia.  Neuralgic  pains  are  usually  confined  to  the  dis- 
tribution of  one  nerve;  they  are  not  increased  by  motion  or  pressure; 
they  are  not  attended  with  diffused  soreness ;  and  they  are  variable  in 
intensity,  and  are  not  attended  with  acid  secretion.  The  tender  spots  of 
Valleix  may  be  detected  along  the  trunk  of  the  nerve  or  in  its  distribu- 
tion. 

2.  From  the  pains  of  organic  lesions.     These  are  usually  so  clearly 


DISEASES   OF  THE   BLOOD.  63 

localized  as  to  point  to  their  origin.  Nevertheless  the  pain  in  the  right 
shoulder,  symptomatic  of  hepatic  disease,  and  especially  of  an  abscess 
approaching  the  serous  surface  of  the  liver,  and  the  sympathetic  pain 
down  the  left  arm  in  some  cases  of  heart  disease,  are  often  carelessly 
looked  over,  and  their  significance  unheeded,  by  classing  them  as  rheu- 
matic. Intercostal  rheumatism  has  included  pleurisy,  pleurodynia, 
broken  ribs,  herpes,  neuralgia,  the  peculiar  pain,  generally  of  the  left 
side,  found  in  women  and  connected  with  menorrhagia  and  leucorrhcea; 
the  pain  on  either  side,  which  is  intimately  connected  with  debility  and 
anaemia;  and  again  is  confounded  with  that  condition  of  pain  and  sore- 
ness of  the  muscle  developed  by  overwork,  and  attended  with  both 
muscular  and  cutaneous  hyperesthesia,  designated  by  Inman  "myalgia." 

3.  From  the  osteocopic  pains  of  syphilis.  The  history  of  the  case 
throws  some  light ;  but  as  this  often  cannot  be  had,  it  should  be  remem- 
bered that  syphilitic  periostitis  evinces  a  decided  partiality  for  the  perios- 
teum and  shafts  of  the  long  bones,  and  is  very  generally  accompanied  by 
nodes,  especially  in  the  anterior  surface  of  the  tibia,  which  are  almost 
pathognomonic.  There  is  often,  too,  a  more  marked  cachexia  than  is 
found  along  with  non-specific  rheumatism.  The  clavicle,  humerus,  and 
forearms,  are  frequent  locations  of  this  form  of  rheumatism.  As  well  as 
its  favorite  seats  and  accompanying  nodes,  there  are  evidences  of  skin 
and  throat  affections,  a  mutilated  iris,  etc.,  which  will  assist  in  formino-  a 
correct  diagnosis.  Furthermore,  the  ready  response  to  a  specific  treat- 
ment aids  in  distinguishing  syphilitic  pains. 

4.  From  progressive  locomotor  ataxia.  Ataxic  patients  often  bitterlv 
complain  of  supposed  rheumatic  pains.  These  pains,  in  locomotor  ataxy, 
come  on  in  severe  pangs — "stabbing,  boring,  shooting  like  lightning 
flitting  from  one  place  to  another  in  a  very  erratic  manner,  and  recurring 
in  paroxysms  lasting  from  a  few  minutes  to  many  hours."  Their  sudden- 
ness is  their  especial  characteristic,  and  should  always  put  the  medical 
observer  on  his  guard  to  look  out  for  the  other  indications,  as  loss  of 
tactile  sensibility,  etc.  These  pains  may  be  accompanied  by  a  feeling  of 
coldness,  thus  closely  simulating  some  forms  of  rheumatism.  The  im- 
portance of  them  lies  in  the  prognosis,  as  the  causes  of  locomotor  ataxv 
are  not  to  be  relieved  by  art,  although  the  pains  may  be  mitigated  by 
anodynes  and  frictions. 


64  DIFFERENTIAL,   DIAGNOSIS. 

5.  The  pains  of  chronic  renal  disease  often  closely  simulate  lumbago, 
or  muscular  rheumatism  of  the  loins.  No  clinical  distinction  can  be 
positively  drawn,  except  from  examination  of  the  urine;  but,  in  some 
forms  of  renal  disease  albumen  is  often  absent  for  long  periods  together. 
Moreover,  the  amount  of  the  urine  varies,  and  when  great  in  quantity 
is  usually  of  low  specific  gravity,  and  contains  granular  casts,  which, 
however,  are  often  fewT  in  number  and  not  easily  found.  An  absolute 
diagnosis  is  not  always  attainable.  In  gouty  kidney  we  may  fall 
back  upon  the  rational  symptoms,  and  the  distinguishing  characteristics 
may  be  found  to  run  in  the  following  directions :  Rheumatism  is  asso- 
ciated with  the  fibro-serous  texture;  in  lithiasis  the  poison  has  more 
affinity  for  the  true  serous  surfaces,  and  is  often  the  cause  of  pleurisy 
and  peritonitis.  Lithiasis  more  affects  the  muscles,  and  rheumatism 
rather  the  large  joints.  Diarrhoea,  vomiting  and  other  affections  of  the 
mucous  membrane,  as  bronchitis,  accompany  lithiasis;  and  in  these  it 
differs  from  rheumatism.  Lithiasis  is  accompanied  by  headache,  especi- 
ally of  the  vertex  (persistent  and  recurring  vertical  headache  is  almost 
pathognomonic  of  lithiasis),  or  the  pain  may  be  frontal.    (Fothergill.) 

6.  A  dislocation  of  the  shoulder  has  been  prescribed  for  as  "  rheuma- 
tism," which  shows  the  necessity  of  inspection  of  affected  joints. 

A  typical  effect  of  the  acid  diathesis  of  chronic  rheumatism  is  the 
rheumatic  markings  of  the  teeth,  to  which  attention  has  been  directed  by 
Dr.  L.  G.  Noel.* 

These  markings  seldom  appear  until  after  middle  life  is  past.  They 
are  most  frequent  upon  the  crowns  of  the  teeth,  though  they  are  some- 
times seen  upon  their  buccal  and  labial  surfaces.  It  is  that  condition  of 
the  teeth  treated  of  in  dental  works  as  "spontaneous  abrasion." 

The  abrasion  often  begins  as  decay  in  the  fissures  on  the  grinding  sur- 
face of  the  molars  and  bicuspids,  but  instead  of  following  the  tubuli, 
and  dipping  deep  into  the  interior  of  the  teeth,  these  become  closed  by  a 
calcareous  deposit,  as  fast  as  laid  open,  and  the  decay  spreads  out  into  a 
wide  saucer-shape.  This  cupping  out  of  the  teeth  is  not,  however, 
confined  to  the  molars  and  bicuspids,  but  commencing  upon  the  cusps 
of  the  canines,  and  cutting  edges  of  the  incisors,  as  mere  mechanical 
abrasion,  asperities  disappear,  the  teeth  become  square  and  polished  on 
*  Nashville  Journal  of  Medicine  and  Surgery,  Feb.,  1875. 


DISEASES   OF   THE   BLOOD. 


65 


the  ends,  and  presently  the  surfaces  begin  to  assume  a  concave,  in 
of  their  original  convex,  appearance.  This  cupping  out  may  go  on 
until  the  pulp  is  so  nearly  reached  as  to  become  irritated  to  the 
point  of  inflammation  and  death;  but  usually  its  irritation  is  only 
sufficient  to  cause  a  deposition  of  secondary  dentine  on  the  interior 
of  its  chamber,  a  part  of  its  substance  forming  a  matrix  in  which  lime- 
salts  are  deposited. 

GOUT. 

The  signs  of  gout  have  already  been  in  part  referred  to  (page  55). 
It  is  not  nearly  so  frequent  in  the  United  States  as  in  England,  and  is 
apt,  therefore,  to  be  mistaken  for  rheumatism,  which  it  closely  resembles. 

The  following  table  of  differences  will  facilitate  the  diagnosis  : — 


GOUT. 

Generally  a  hereditary  history. 

Occurs  usually  in  males,  beyond 
middle  age. 

Attacks  generally  periodic,  and 
last  about  a  week. 

The  small  joints  chiefly  affected, 
especially  that  of  the  great  toe,  or 
lower  extremity. 

Much  local  pain,  redness,  oedema, 
and  enlargement  of  veins. 

Kidneys  generally  affected;  little 
fever;  no  sweating;  heart  not  im- 
plicated. 

Chalk  stones  in  the  joints  and  ears. 

Uric  acid  always  present  in  the 
blood  in  large  excess  (Gaerod). 


RHEUMATISM. 
Rarely  hereditary. 

Occurs  oftener  in  females,  and 
before  middle  age. 

Attacks  dependent  on  exposure, 
and  last  several  weeks. 

The  large  joints  are  those  generally 
attacked. 

All  these  symptoms  less  marked. 

Kidneys  not  involved ;  fever  often 
high ;  sweating  profuse ;  heart  often 
implicated. 

Chalk  stones  never  present. 

Uric  acid  never  found  in  excess. 


Dr.  Garrod  says  that  the  presence  of  uric  acid  in  the  blood  can 
readily  be  demonstrated  by  taking  a  fluidrachm  of  the  serum  from  a 
blister,  adding  to  it  six  minims  of  acetic  acid,  and  placing  a  thread  in 
the  mixture.  The  uric  acid,  if  present,  will  be  deposited  in  fine  crystals 
along;  the  thread. 


G6  DIFFERENTIAL   DIAGNOSIS. 

RHEUMATOID  ARTHRITIS  (RHEUMATIC  GOUT, 
ARTHRITIS  RHEIMATTCA  DEFORMANS). 

This  is  by  no  means  an  infrequent  disease  in  this  country,  and  is  a 
very  serious  one.  It  is  now  acknowledged  by  the  best  authorities  to  be 
a  distinct  malady,  different  in  origin,  history  and  treatment  from  both 
rheumatism  and  gout.  It  is  common  in  women  and  young  persons,  and 
is  not  produced  by  alcoholic  or  other  excesses.  It  implicates  joints  of 
all  sizes,  and  in  all  the  extremities.  They  become  permanently  affected, 
stiffened  and  enlarged,  but  no  deposits  of  urate  of  soda  are  found 
in  them.  The  disease  frequently  shows  itself  without  fever;  the  joints 
swell  by  serous  effusions  into  the  capsules,  and  along  with  this 
the  ends  of  the  bones  enlarge.  The  integument  is  not  inflamed,  or 
but  moderately  so,  and  the  muscles  do  not  appear  to  suffer.  The 
result  on  the  joint  may  be  subluxation,  relaxation,  or  anchylosis.  The 
concretions  attendant  on  the  disease  prove,  on  analysis,  to  be  of  the 
same  composition  as  bone,  with  a  slight  preponderance  of  lime 
(Drachmann).  Phosphoric  acid  is  diminished  in  the  urine  and  in- 
creased in  the  blood  (Bocher). 

Neither  the  treatment  of  gout  nor  that  for  acute  rheumatism  yields  its 
usual  results  in  this  disease. 

PERNICIOUS  ANAEMIA  AND  LEUKiEMIA. 

The  positive  diagnosis  of  these  conditions  can  only  be  secured  by  a 
microscopic  examination  of  the  blood. 

In  pernicious  anaemia,  according  to  Dr.  Eichhorst,  the  characteristic 
appearances  are :  A  portion  of  the  red  corpuscles  are  seen  to  retain  their 
normal  size,  but  are  marked  by  an  extreme  paleness,  with  a  tendency  to 
crenation  and  the  formation  of  rouleaux,  while  others  among  them  attract 
attention  by  their  small  size,  which  is  reduced  often  to  one-fourth  the 
diameter  of  the  well  formed  corpuscles.  These  small  ones  are  more 
deeply  colored,  and  if  allowed  to  roll  over  under  the  thin  cover-glass, 
their  appearance  in  profile  shows  them  to  have  lost  to  a  greater  or  less 
extent  their  bi-concave  outline. 

For  the  examination  of  the  blood  in  such  investigations,  Dr.  Gowers, 
of  London,  recommends  the  use  of  the  hcBmacytometer,  by  which  he 


DISEASES   OF  THE   BLOOD.  07 

measures  for  the.  purpose  of  ascertaining  the  number  of  red  and  vrhite 
cells  in  a  given  volume  of  blood.  The  essential  part  of  the  apparatus 
consists  of  a  glass  slip,  on  which  is  a  cell  one-fifth  of  a  millimetre  (.008 
inch)  deep.  The  bottom  of  this  cell  is  divided  into  one-tenth  millimetre 
squares.  Upon  the  top  of  the  cell  rests  the  glass  cover,  which  is  kept  in 
its  place  by  the  pressure  of  two  springs.  In  estimating  the  number  of 
corpuscles,  the  patient's  finger  is  pricked;  then  by  means  of  a  capillary 
pipette,  five  cubic  millimetres  of  blood  are  taken  up  and  well  mixed  up 
with  995  cubic  millimetres  of  saline  solution;  a  drop  of  the  dilution  is 
then  placed  in  the  glass  cell,  the  cover  is  adjusted,  and  -the  slide  is 
placed  in  the  field  of  a  microscope.  In  a  few  minutes  all  the  cor- 
puscles have  sunk  to  the  bottom  of  the  cell,  and  are  seen  lying  on  the 
squares ;  the  number  of  corpuscles  in  ten  squares  is  then  counted,  and 
this,  multiplied  by  10,000,  gives  the  number  in  a  cubic  millimetre  of 
blood.  The  degree  of  dilution  and  size  of  the  squares  are  so  proportioned 
that,  with  normal  blood,  two  squares  contain  about  100  corpuscles,  and 
the  number  in  two  squares  thus  expresses  the  percentage  proportion  of 
corpuscles  to  that  of  health.  The  proportion  of  white  corpuscles  to  red, 
or  their  absolute  number,  may  be  easily  determined  during  the  same 
observation. 

A  simpler  method  is  used  by  Dr.  J.  G.  Richardson,  of  Philadelphia. 
He  spreads  a  drop  of  fresh  blood  thinly  on  a  glass  slide,  letting  it  dry, 
and  then  counting  the  number  of  white  corpuscles.  The  specimens  when 
thus  prepared  can  be  kept  dry  for  any  length  of  time,  if  preserved  from 
dust  and  moisture,  and  by  comparing  specimens  of  different  persons' 
blood,  prepared  similarly,  the  variations  in  the  number  of  white  corpuscles 
can  be  readily  observed.  By  this  means  he  claims  to  detect  leukaemia  in 
its  early  stages. 

Profound  anaemia  is  met  with  in  the  following  conditions :  (1)  After 
great  loss  of  blood  or  exhausting  discharges ;  (2)  where  there  is  inanition 
(insufficient  nourishment) ;  (3)  in  chlorosis ;  (4)  in  cases  of  malignant 
disease ;  (5)  in  Bright's  and  Addison's  disease,  (6)  leucocythemia,  and  (7) 
chronic  metallic  poisoning. 

The  symptoms  of  the  idiopathic  or  "  progressive  pernicious  "  form  of 
anaemia  are  described  by  Dr.  Byron  Bramwell  as  follows :  A  profound 
anaemia,  which  is  associated  with  marked  changes  in  the  microscopical 


68  DIFFERENTIAL   DIAGNOSIS. 

characters  of  the  blood,  and  (in  most  cases)  with  the  presence  of  retinal 
hemorrhages.  The  patient  is  generally  well  covered  with  fat,  the  skin  is 
smooth  and  soft,  the  face  looks  slightly  swollen,  and  is  of  a  pale  yellow 
or  yellowish-green  color.  All  the  symptoms  of  profound  anaemia  arc 
present,  viz.,  extreme  pallor  of  the  mucous  membrane,  great  debility, 
tendency  to  fainting,  dyspnoea  and  palpitation  on  exertion,  buzzing  in  the 
cars,  headache,  subcutaneous  oedema,  etc.;  loud  blowing  murmurs  are 
heard  over  the  heart  and  great  vessels ;  there  is  a  venous  hum  in  the 
neck  ;  the  pulse  is  very  soft  and  compressible.  Attacks  of  vomiting  and 
diarrhoea  are  frequent;  irregular  elevations  in  temperature,  transient 
paralyses,  hemorrhages  from  the  mucous  membranes  occasionally  occur. 
The  causes  of  the  disease  are  at  present  unknown.  The  disease  is  said  to 
occur  more  frequently  in  women  than  in  men.  In  the  majority  of  cases 
the  termination  is  in  death,  the  end  being  ushered  in  by  profuse  diarrhoea, 
coma,  or  delirium. 

THE  ORIGIN  OF  ZYMOTIC  DISEASE,  AND  THE 
SO-CALLED  GERM  THEORY. 

The  following  is  an  abstract  of  an  instructive  and  elaborate  paper  by 
Dr.  D.  D.  Cunningham,  on  the  "  Development  of  Certain  Microscopic- 
Organisms  occurring  in  the  Intestinal  Canal,"*  which  is  introduced  here 
because  it  has  a  direct  bearing  upon  the  so-called  germ  theory  of  disease 
that  is  now  exciting  much  discussion : — 

"  At  a  time  when  the  association  of  special  parasites  with  morbid  states 
of  their  host  is  readily  interpreted  as  evidence  in  favor  of  current  theories 
regarding  the  parasitic  origin  of  disease,  any  exact  information  regarding 
the  true  significance  of  the  phenomenon  in  particular  cases  may  serve  a 
useful  purpose." 

Monads  and  amoeba?  in  excessive  numbers  are  met  with  in  the  intes- 
tinal canal  in  cholera  and  certain  other  conditions  characterized  by  special 
characters  of  intestinal  contents.  Davaine  appears  to  have  been  the  first 
to  observe  them,  during  the  cholera  epidemic  of  1853-54.  Similar  bodies 
have  been  described  by  others  in  diarrhoea,  typhoid  fever,  and  dysentery. 
Drs.  Cunningham  and  Lewis  recorded  the  occurrence  of  amoebal  orgau- 

*  Fifteenth  Annual  Report  of  the  Sanitary  Commissioner  with  the  Government  of 
India,  1878.     Calcutta,  1880.     Notice  of,  in  Medical  Herald,  Louisville,  July,  1880. 


DISEASES   OF  THE   BLOOD.  69 

isms  in  choleraic  and  other  excreta  in  1870-71,  and  Losch,  in  1875,  as- 
sumed that  amoebae  eoli  was  the  specific  cause  of  a  dysenteric  condition  of 
the  large  intestine. 

The  monads  present  in  the  digestive  canal  of  man  in  India  present 
characters  entitling  them  equally  to  a  place  in  two  genera — cercomonas 
and  trichomonas.  These  monads,  or  zoospores,  exhibit  no  constancy  of 
form,  but  are  continually  varying,  in  consequence  of  both  intrinsic  and 
extrinsic  influences.  The  body  in  most  cases  is  a  mere  fragment  of  naked 
protoplasm,  with  no  differentiated  covering,  and  with  hardly,  if  any,  in- 
dications of  a  differentiation  of  ectosarc  and  endosarc.  Owing  to  this  and 
to  their  minute  size  it  is  almost  impossible  to  determine  with  any  certainty 
many  points  regarding  it  when  in  a  state  of  full  activity.  Nearly  all 
reagents  almost  immediately  produce  destructive  changes,  leading  on 
rapidly  to  disintegration  and  disappearance,  and  even  slight  changes  in 
the  medium,  such  as  depression  of  temperature  or  dilution  with  water, 
are  sufficient  to  arrest  activity  and  induce  disintegration. 

The  presence  of  zoospores  is  by  no  means  confined  to  choleraic  excreta. 
The  two  media  best  adapted  to  secure  the  demonstration  of  their  presence 
are,  first,  the  alkaline  fluid  of  choleraic  excreta ;  and  second,  a  solution 
of  cow-dung. 

The  zoospores  are  not  peculiar  to  any  diseased  condition.  Indeed, 
certain  diseases  associated  with  an  acid  reaction  of  intestinal  secretions 
are  incompatible  with  their  presence.  That  they  have  been  rarely  de- 
tected in  Europe  is  probably  due  to  their  ready  destruction  by  very  slight 
reduction  of  temperature.  Other  infusorial  organisms  are  prejudicially 
affected  by  the  initial  fermentative  changes  occurring  in  the  excreta. 

Monads  and  amoebae  abound  in  the  excreta  of  horses  and  cows.  There 
are  less  bacterial  elements  in  vaccine  than  human  discharges. 

As  bearing,  perhaps  remotely,  on  the  phenomena  of  periodicity  of  dis- 
ease, there  is  a  very  interesting  observation  by  Dr.  Ctjxxixgham  relating 
to  the  periodicity  of  sporangial  development.  In  cultivation  experi- 
ments, while  at  dawn  there  would  be  no  trace  of  sporangia,  an  abundant 
crop  of  such  bodies  appeared  within  the  course  of  a  few  hours.  The 
development  is  regularly  limited  to  the  period  between  dawn  and  noon,  or 
at  least,  1  p.m.  If  sporangia  have  not  appeared  by  the  latter  hour  they 
will  not  appear  until  the  following  morning.     At  first  sight  it  appeared 


70  DIFFERENTIAL  DIAGNOSIS. 

not  improbable  that  light  conditions  were  the  determinant  of  this  phe- 
nomenon, but  experiments  proved  that  this  was  not  so,  for  the  develop- 
ment followed  the  same  course,  even  where  all  light  was  carefully  and 
absolutely  excluded. 

Dr.  Cunningham  asserts  that  the  characteristic  parasitic  zoospores  and 
amoeba?  of  human  and  vaccine  excreta  are  identical,  and  this  affords  a 
ready  explanation  of  the  extreme  frequency  of  the  parasite  in  the  human 
subject,  owing  to  the  presence  of  a  constant  source  of  readily  transferred 
reproductive  elements.  This  transfer  is  principally  effected  through  the 
air.  The  sporangia  when  thoroughly  dried  are  detached,  by  the  slightest 
contact,  from  their  points  of  attachment,  and  having  been  so  are  so  light 
as  readily  to  be  carried  about  by  breezes.  Desiccated,  these  sporangia 
probably  resist  fairly  the  action  of  the  gastric  juice;  active  or  softened, 
they  might  fail,  more  easily  than  if  dried,  to  reach  unhurt  the  lower  por- 
tions of  the  digestive  canal. 

Dr.  Cunningham's  conclusions  are  as  follows  : — 

"  1 .  Special  parasitic  forms  may  be  specially  associated  with  particular 
forms  of  disease  without  holding  any  causal  relation  to  them. 

"  2.  The  monadic,  amcebal,  and  sporoid  bodies,  so  abundant  in  many 
choleraic  excreta,  are  all  developmental  forms  of  one  species  of  parasite, 
which  I  propose  to  call  Protomyxomyces  coprinarius. 

"  3.  This  parasite  appears  to  be  closely  related  to  the  organisms  in- 
cluded within  the  Protist  groups  of  Protomonadina?  and  Myxomycetes, 
and  in  certain  respects  seems  to  represent  a  connecting  link  between  them. 

"  4.  It  is  not  confined  to  choleraic  or  even  to  human  excreta  as  a  basis, 
and  only  attains  its  full  development  external  to  the  bodies  of  the  animals 
within  which  it  occurs. 

"  5.  Its  immature  forms  occur  parasitically,  as  normal  inmates  of  the 
digestive  canal  in  certain  of  the  lower  animals. 

"6.  In  the  human  subject,  both  in  health  and  disease,  they  are  very 
frequently  present  in  varying  numbers. 

"  7.  During  health  their  number  and  activity  are  limited,  due  to  re- 
pressive influences  exerted  by  the  normal  intestinal  contents  as  a  medium. 

"  8.  Their  excessive  abundance  in  certain  forms  of  disease  is  due  to 
abnormal  conditions  of  the  intestinal  contents,  permitting  of  processes  of 
rapid  multiplication. 


DISEASES   OF   THE   BLOOD.  71 

"9.  Normal  human  excreta  do  not  form  a  medium  in  which  any 
further  development  of  the  parasitic  elements  outside  the  host-body  can 
occur. 

"10.  On  the  contrary,  the  normal  series  of  fermentative  changes 
through  which  the  excreta  pass  after  exit  from  the  body,  insures  the 
complete  destruction  of  the  parasitic  elements. 

"11.  No  such  destructive  effect,  however,  is  exerted  by  the  changes 
occurring  during  the  decomposition  of  the  excreta  in  certain  lower  ani- 
mals, especially  cows  and  horses;  and  here  the  parasitic  elements,  on  their 
escape  from  the  body,  undergo  further  processes  of  development,  resulting 
in  the  production  of  reproductive  bodies,  securing  the  continuance  and 
diffusion  of  the  species. 

"  12.  Such  excretal  matters,  therefore,  serve  as  a  constant  source 
whence  parasitic  elements  may  be  transformed  in  the  bodies  of  other 
animals. 

"  13.  Human  excreta  which  have  passed  through  the  initial  processes 
of  decomposition,  and  which  have  thus  become  alkaline,  allow  of  the  con- 
tinued existence  and  multiplication  of  elements  of  the  parasite  which  may 
then  obtain  access  to  them,  and  may  thus  serve  as  a  second  centre  of  re- 
production. 

"  14.  The  introduction  of  the  reproductive  elements  of  the  parasite  into 
the  human  body  is  mainly  effected  through  the  medium  of  the  air. 

"15.  The  introduction  of  the  reproductive  elements  'per  se  seems  to  be 
quite  innocuous. 

"16.  The  special  association  of  the  parasite  with  intestinal  disorders 
appears  to  be  dependent  on  the  abnormal  condition  of  the  intestinal  con- 
tents, allowing  of  the  rapid  multiplication  of  reproductive  elements  which 
may  obtain  access  to  them. 


PART  II 

LOCAL    DISEASES. 


CHAPTER  I. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

Contents.  —  Cerebral  Disorders — Congestion — Anosmia — Apoplexy — 
Thrombosis  — Embolism  — Meningitis — Tubercular  Meningitis  — Rheu- 
matic Meningitis — Acute  Cerebritis — The  Ophthalmoscope  in  Nervous 
Disorders  — Headache — Chronic  Cerebral  Disoixlers — Hypertrophy — 
Hydrocephalus — Brain  Tumor —  White  Softening — Abscess — Chronic 
Meningitis — Thrombosis — Sclerosis — Localization  of  Brain  Disease — 
Lesions  of  Cerebral  Cortex —  Brain  Lesions  other  than  Cortical — Tab- 
ular View  of  Paralysis  with  Seat  of  Lesion — Spinal  Disease — Organic 
and  Functional  Paraplegia — Diagram  of  Spinal,  Lnflammatory  and 
Degenerative  Diseases — Tabular  View  of  Spinal  Paralysis,  Congestion, 
Meningeal  Apoplexy,  Spinal  Apoplexy,  Acute  Primary  Myelitis — 
Comparison  of  Acute  Spinal  Disorders — Tumors — Tremors — Chronic 
Degenerative  Diseases  of  the  Cord — Prof.  Charcot's  Diagnostic  Chart 
of  Cerebro-Spinal  Affections — Patellar- Tendon  Reflex  of  Westphal — 
Analysis  of  Symptoms  of  Focal  Lesions  of  the  Cord  (Gowers,  Charcot, 
and  Frb) — Comparative  Semeiology  of  Cerebro-Spinal  Sclerosis,  Paraly- 
sis Agitans,  and  Locomotor  Ataxia — Paraplegia  from  Reflex  Irrita- 
tion and  Myelitis  Compared —  Gowers'  Classification  of  Spinal  Lesions 
— Pseudo-Hypertrophic  Pairdysis — Lead  Palsy — Hysterical  Paralysis 
— General  Paralysis  of  the  Insane — Sjnnal  Irritation,  and  Spinal 
Weakness — Hysteria  and  Hystero- Epilepsy — Neuralgia — Insanity,  Its 
Different  Forms;  their  Pathology  and  Etiology. 

Recent  advances  in  the  physiology  of  the  nervous  system  have  thrown 
much  light  upon  mental  and  nervous  manifestations ;  and  many  con- 

73 


74  ,  DIFFERENTIAL   DIAGNOSIS. 

ditions  which  had  been  hitherto  regarded  as  primary  have  been  shown  to 
be  in  reality  symptomatic  and  secondary  to  definite  morbid  changes 
occurring  either  in  the  central  nervous  system,  the  trunks  of  the  nerves, 
or  in  their  peripheral  terminations.  It  is  evident  that  diseases  having 
their  origin  or  seat  of  lesion  in  the  nervous  system  will  vary  in  their 
symptoms  with  the  locality  of  the  morbid  process  and  the  function  of 
the  part  affected.  Disorders  of  intellection  and  insanity  result  from 
involvement  of  the  cerebral  hemispheres,  with  impairment  of  special 
senses,  and  paralysis  of  parts  supplied  by  cranial  nerves,  and  occur- 
ring with  or  without  loss  of  power  in  the  extremities.  Diseases  of  the 
spinal  cord  give  rise  to  paralysis  of  organs  having  direct  connection  with 
the  seat  of  lesion,  and  also  to  disorders  of  sensation  and  nutrition. 
Hemiplegia  may  be  of  cerebral  origin ;  paraplegia  is  generally  spinal. 
Pressure  or  irritation  of  nerve  trunks  may  cause  local  palsy,  spasmodic 
affection,  or  neuralgia,  while  myopathic  paralysis  (such  as  encountered 
in  lead  palsy,  pseudo-hypertrophic  paralysis,  and  progressive  muscular 
atrophy)  may  be  due  to  a  peripheral  nervous  affection.  Hysteria, 
vertigo,  neurasthenia  and  some  mental  disorders,  being  of  uncertain  seat 
and  unknown  relations,  may  be  provisionally  considered  as  functional 
disorders  of  the  nervous  system. 

The  principal  symptoms  referable  to  the  brain  may  be  considered  as 
being  caused  by  congestion,  anseinia,  apoplexy,  thrombosis,  embolism, 
brain  tumor,  cerebritis  and  abscess;  by  influence  upon  the  brain  disease 
of  neighboring  structures,  such  as  meningeal  inflammation,  hemorrhage, 
effusion  or  neoplasm,  necrosis,  disease  of  the  middle  ear ;  and  by  poisoned 
conditions  of  the  blood,  as  in  ursemia,  alcoholism,  and  the  delirium  of 
fevers.  An  irregular  and  abnormal  distribution  of  the  blood  supply 
may  give  rise  to  night  terrors,  epilepsy,  syncope,  temporary  (functional  ?) 
paralysis,  cerebral  exhaustion,  aphasia,  aphemia  and  agraphia ;  and 
irregular  motor  discharges  from  the  cerebral  centres  are  directly  associated 
with  chorea,  tremor,  and  epileptiform  convulsions;  the  higher  mental 
jjowers  being  apparently  merely  held  in  abeyance  in  catalepsy,  trance 
and  hysterical  coma. 

Passing  to  the  diagnosis  of  the  principal  cerebral  disorders,  the  follow- 
ing points  are  of  importance  in  distinguishing  cerebral  congestion  and 
cerebral  anaemia,  which  sometimes  are  difficult  of  clinical  separation  and 
diagnosis : — 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


75 


CEREBRAL  CONGESTION. 

Severe,  throbbing  and  diffused.  Headache. 

May  be  absent.  Vertigo. 

Full,  throbbing,   tortuous   and  Temporal 
distinct.  Vessels. 

Full,  tense  ;  often  signs  of  pie-  General 

thora.  Circulation. 

May  be  rumbling  or  singing.       Tinnitus  aurium. 


Hallucinations  ;  may  have  ac- 
tive delirium. 

Surface  temperature  of  scalp 
may  be  increased. 

Contracted. 

Not  increased ;  may  contain 
urates  and  phosphates  (Ham- 
mond). 


Mental 
Phenomena. 

Temperature. 

Pupils. 
Urine. 


CEREBRAL  ANEMIA. 
Less  sharp,  generally  vertical. 
Usually  a  marked  symptom. 
Not  prominent. 

Pulse  irritable,   often  ana;mic 
murmur  of  pulmonary  artery. 

Noises  may  be  short  and  high- 
pitched. 

Below  normal  ;    incapacity  for 
mental  application. 

Surface  temperature,  if  at  all 
affected,  is  diminished. 

Dilated. 

Limpid,    and    may  be  passed 
in  excess  :  decrease  of  salts. 


Cerebral  exhaustion  is  sometimes  so  marked  as  to  produce  coma,  and 
thus  form  a  variety  of  apoplexy,  and  its  diagnosis  is  made  by  excluding 
hyperemia,  hemorrhage,  embolism  and  thrombosis  of  basilar  artery. 
Where  the  latter  condition  terminates  in  recovery,  it  is  almost  identical  in 
its  manifestations;  indeed,  "it  would  be  difficult  to  disprove  the  asser- 
tion that  cases  of  cerebral  exhaustion  belong  in  this  category"  (Flest). 

A  sudden  attack  of  coma  iu  a  case  of  albuminuria  may  be  set  down 
as  due  to  urcemia,  if  embolism  and  apoplexy  are  excluded  (by  noting  the 
absence  of  hemiplegia).  Should  the  coma  be  associated  with  epilepti- 
form convulsions  this  diagnosis  is  likely  to  be  correct,  even  if  no 
albumen  can  be  detected  in  the  urine;  since  the  form  of  renal  disease 
most  likely  to  give  rise  to  ursemic  poisoning  is  the  cirrhotic  form  (con- 
tracted kidney),  in  which  the  albumen  may  be  absent  from  the  urine  for 
considerable  periods  of  time. 

The  early  diagnosis  of  diseases  attended  by  coma  is  of  great  import- 
ance, with  the  view  of  promptly  instituting  proper  treatment. 

CEREBEAL  APOPLEXY. 

Apoplexy  is  to  be  distinguished  from  drunkenness,  narcotic  poisoning, 
uraemic  poisoning,  epilepsy,  concussion  of  the  brain,  cerebral  thrombosis, 
embolism,  and  insolation  or  sunstroke. 


7G  DIFFERENTIAL   DIAGNOSIS. 

Drunkenness.  The  odor  of  liquor  may  excite  suspicion.  If  the 
patient  vomit,  the  ejecta  may  be  tested  for  alcohol.  Or  the  urine  may 
be  examined  by  Anstie's  test,  as  follows  : — 

R.     Bichromate  of  potash,  1  part 

Strong  sulphuric  acid,  300  parts.  Mix. 

To  fifteen  minims  of  this  add  a  few  drops  of  the  urine,  and  if  the 
patient  has  taken  a  toxic  dose  of  alcohol,  the  mixture  will  turn  an 
emerald  green.  In  drunkenness  the  pulse  is  generally  rapid,  the  pupils 
not  dilated,  the  eye  injected.     The  patient  can  be  roused  and  hiccoughs. 

Dr.  MacEwen,  of  Glasgow,  gives  the  following  method  of  distin- 
guishing alcoholic  coma  from  that  of  apoplexy,  fracture  of  the  skull, 
and  other  causes.  In  alcoholic  coma,  as  long  as  the  patient  is  undis- 
turbed the  pupil  is  contracted ;  but  if  any  stimulus  not  sufficient  to 
arouse  the  patient  be  applied  to  him,  such  as  a  shake  or  a  pull  of  the 
beard,  the  pupil  dilates,  only,  however,  to  become  contracted  again  as 
soon  as  the  person  is  left  at  rest.  * 

Narcotic  poisoning.  In  this  condition  the  outset  is  gradual;  there  are 
often  convulsions,  but  the  patient  may  be  roused.  In  opium  poisoning 
the  pupil  is  contracted ;  so  it  is  in  hemorrhage  in  the  pons.  The 
vomiting,  the  acrid  odor  of  opium,  and  the  gradual  intensification  of  the 
coma  are  diagnostic.     There  is  no  hemiplegia. 

Urcemic  poisoning.  Here  the  coma  nearly  always  comes  on  gradually 
and  is  preceded  by  convulsions.  It  is  not  deep,  and  at  first  the  patient 
may  be  aroused.  The  stertor  of  the  breathing  is  more  superficial,  while 
there  is  also  frothing  at  the  mouth. 

Nearly  always,  distinctive  modifications  of  the  heart  sounds  will  be 
heard,  as  reduplication  of  one  or  both,  intensity  of  second  sound,  etc.; 
while  there  are  elevation  of  the  arterial  tension  and  increased  cardiac 
impulse.  Of  these  cardiac  physical  signs  none  seem  so  constant  or 
remarkable  as  muffling  of  the  first  sound.     (Mr.  "W.  Whittle.) 

There  are,  moreover,  in  many  cases  marked  prodromata.  The  skin 
has  been  waxy  and  oedematous,  the  eyelids  puffed  and  the  legs  and  feet 
swollen.  The  urine  may  or  may  not  be  albuminous  (but  this  may  also  be 
present  in  apoplexy). 

Epileptic  coma  presents  a  history  of  convulsions ;  lasts  but  for  an  hour 
*  British  Medical  Journal,  November  16,  1878. 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


77 


or  two;  there  is  frothing  at  the  mouth;  and  the  temperature  is  ele- 
vated. 

In  hysteria  and  catalepsy  there  is  no  elevation  of  temperature  and  no 
frothing  at  the  mouth. 

In  concussion  or  compression  from  injuries  to  the  head  the  skin  is 
pale,  the  pupil  dilated,  and  vomiting  occurs.  The  symptoms  are 
usually  of  short  duration  and  there  is  a  history  of  injury.  Meningeal 
hemorrhage  from  injury  presents  no  points  of  difference  from  true 
apoplexy,  except  that  hemiplegia  is  generally  wanting  (Flint). 

Syncope  is  readily  distinguished  by  the  feeble  pulse,  the  pale  face,  the 
quiet  respiration  and  the  brief  duration  of  the  unconsciousness  ;  while 
in  asphyxia  the  livid  face,  distressed  breathing  and  blue  lip  which  precede 
the  coma  indicate  its  distinction. 

In  regard  to  thrombosis  and  embolism  of  the  larger  cerebral  vessels  the 
diagnosis  is  often  extremely  difficult.  The  following  table  of  the  com- 
parative symptoms  is  drawn  up  from  the  works  of  Buduy,  Gelpke, 
Flint  and  Hamilton  : — 


CEREBRAL    HEMORRHAGE. 

Occurs  in  advanced  age, 
with  atheromatous  arteries. 


Onset  generally  sudden. 

Hypertrophy  of  left  ven- 
tricle. Alcoholism  or  other 
debilitating  habits. 


Pain  in  the  head. 

Aphasia  ataxic,  second- 
ary to  a  loss  of  conscious- 
ness. Intelligence  much 
involved. 

Often  coma. 


Paralysis    very  marked ; 
occurs  on  either  side. 


CEREBRAL  THROMBOSIS. 

In  advanced  age.  May 
occur  in  children  during 
scarlet  fever  and  renal  dis- 


Development  of  symp- 
toms gradual. 

No  rheumatic  history. 
Endarteritis  deformans  of 
peripheral  arteries  some- 
times present. 


No  headache. 

Aphasia  incomplete  and 
primary,  occasionally  ab- 
sent. Intelligence  less  in- 
volved. 

Earely  loss  of  conscious- 
ness. 

Paralysis  less  marked. 


CEREBRAL   EMBOLISM. 

Almost  always  in  early  or 
middle  life  (Flixt). 


Prodromata  absent. 

Previous  articular  rheum- 
atism or  other  disease  lead- 
ing to  formation  of  clots. 
Often  cardiac  valvular  in- 
sufficiency. Coincident  em- 
bolisms are  sometimes  pre- 
sent. 

No  headache. 

Aphasia  amnesic.  Reten- 
tion of  mental  power. 


No  coma. 

Muscular  paralysis  exten- 
sive ;  nearly  always  on  the 
right  side  (Flint). 


78 


DIFFERENTIAL    DIAGNOSIS. 


CEREBBAL  THBOMBOSIS. 

No  apoplectic  phenomena 

at  onset. 


llceovery  slow  :  more  or 
less  hemiplegia  may  re- 
main. 


May  have  oedema  more 
marked  on  affected  side. 


CEREBBAL   EMBOLISM. 

Early  apoplectic  pheno- 
mena, bul  without  loss  of 
consciousness. 

Very  rapid,  or  else  quite 
imperceptible  disappear- 
ance of  the  residual  disor- 
der. May  be  followed  by 
softening. 

One-sided  oedema,  often 
in  the  arm  alone. 


CEREBRAL  HEMORRHAGE. 

Apoplectic  phenomena 
from  the  outset.  Symptoms 
of  cerebral  pressure. 

1  disappearance  of  the  res- 
idual disorder  after  a  mod- 
erate time.     May  terminate 

in  chronic  abscess. 

After  a  few  days  pain  in 

the  head  and  inei 

perature  of  the  body  on  the 

unaffected  side  (Flint). 

The  high  temperature  (108°  to  113°  F.)  of  cases  of  sunstroke  serves 
to  distinguish  such  from  the  coma  of  apoplexy ;  although  iu  some  cases  of 
insolation  the  coma  is  probably  due  to  cerebral  exhaustion,  the  distinguish- 
ing features  of  which  have  been  previously  considered.  The  subjects 
attacked  are  generally  laboring  men,  who  have  been  exposed,  while  at 
their  work,  to  a  continuous  high  temperature. 

ACUTE  CEREBRAL  INFLAMMATIONS. 

Considering  the  acute  inflammatory  state  of  the  brain  and  its  cover- 
ings, we  tabulate  their  comparative  semeiology  as  follows  : — 


SIMPLE  MENINGITIS. 

(Lcplo-meniwjitie.) 

Due  to  disease  of 
the  cranial  bones, 
traumatism,  expo- 
sure to  sun.  (Very 
frequently  the  me- 
ningitis o  f  young 
adults  has  a  syphi- 
litic source.)  Maybe 
epidemic. 

A  disease  of  both 
infants  and  adults, 
though  usually  in  the 

latter. 

Previously  healthy; 
no  prodromata. 


No    chest    symp- 
toms. 


TUBERCULAR 
MENINGITIS. 

Scrofulous  inherit- 
ance. 


Often  children  un- 
der five  years  of  age. 


I  [istory  of  persist- 
ent headache  and 
obstinate  constipa- 
tion; wasting. 

Previous  pulmo- 
nary trouble. 


RHEUMATIC 
MENINGITIS. 

Rheumatic 

diathesis. 


Adults. 


Often  during  an 
attack  of  joint  in- 
flammation. 


None. 


ACUTE  CEREBRITIS 

AND  CEREBRAL 

ABSCESS. 

May  be  due  to 
general  causes,  such 
as  pyasmia,  etc.,  or 
to  local  causes,  as 
traumatism,  bone 
disease,  local  irrita- 
tion, extension  from 
meninges,  etc. 

Often    in    elderly 

subjects. 


Rarely  occurs  in 
previously  healthy 
persons. 


None. 


DISEASES    OF  THE    NERVOUS   SYSTEM. 


79 


SIMPLE  MENINGITIS. 
(Lepto-meningilis.) 

Onset  sudden. 


Headache  intense 
on  both  sides  o  f 
head. 

Pupils  contracted. 


Intelligence  clear 
at  first,  but  may  be- 
come furiously  deli- 
rious. 

Vomiting  early, 
frequent. 

Pulse  f u  1 1  and 
rapid. 

High  fever. 

Convulsions  early, 
contracted  pupils, 
with  contractions  of 
flexor  muscles  o  f 
arm  or  leg. 

In  fatal  cases 
death  generally  oc- 
curs in  a  week  ;  re- 
covery is  slow. 

Prognosis  favor- 
able under  prompt 
treatment. 


TUBEBOULAR 
MENINGITIS. 

Takes  four  or  five 
days  to  develop;  ap- 
proach insidious. 

Persistent  a  n  d 
marked  headache, 
which  exacerbates. 

Pupils  irregularly 
dilated. 

Delirium  of  low 
grade  at  night  (stu- 
por in  second  stage); 
strabismus,  and  os- 
cillation of  eyeballs. 

Vomiting  occa- 
sionally. 

Irregular  and  slow 
pulse. 

Fever  not  intense. 

Convulsions  late, 
with  dilated  pupils 
and  hemiplegia. 


Lasts  from  one  to 
three  weeks. 


Prognosis    unfav- 
orable. 


RHEUMATIC 
MENINGITIS. 

Rapidly  developed. 
Intense  pain. 


Leads    to     active 
delirium. 


Not  marked. 

Pulse     full    and 
rapid. 

Temperature  may 
be  very  high. 
No  convulsions. 


Lasts  a  few  days; 
death  often  occurs 
from  continued  high 
temperature. 

Prognosis  fair. 


ACUTE  CEREBRITIS 
AM)  CEREBRAL 

ABSCESS. 
Slow,    and    may 
simulate  typhoid. 

Dull ,   per 
and  localized;   less 
than  in  meningitis. 


Mental  confusion 
and  impairment  of 
intelligence. 


Vomiting  not  in- 
frequent. 


Less  fever. 

No  convulsions  ; 
but  sudden  hemi- 
plegia may  occur. 


Course     is     often 
chronic. 


Prognosis  not  en- 
couraging. 


Dr.  Gee  notes  that  meningitis  of  the  base  of  the  brain  is  generally 
tubercular ;  and  when  tubercular  meningitis  attacks  the  convexity,  there 
is  a  constant  convulsive  condition,  moderate  force  and  very  variable 
pulse.  (See  page  48  for  a  more  detailed  account  of  tubercular  menin- 
gitis.) 

These  cerebral  diseases  may  be  distinguished  from  typhoid  fever  by 
the  history  and  course  of  the  affection.  Typhoid  occurs  in  the  spring 
and  fall,  and  is  often  endemic;  it  never  appears  in  children  under  five, 
and  generally  attacks  young  adults.  It  is  a  continued  fever,  coming  on 
in  a  hitherto  healthy  person  with  malaise,  epistaxis  and  diarrhoea.  Chills 
and  vomiting  are  rare.    Convulsions  and  paralysis  are  late  manifestations, 


80  DIFFERENTIAL   DIAGNOSIS. 

and  duo  to  complications.  Delirium  of  low  type,  headache  dull,  moderate 
deafness,  pulse  rapid  but  regular.  Abdominal  symptoms  generally  pro- 
minent, tympanites,  diarrhoea,  tenderness  and  gurgling  on  pressure  in 
the  right  iliac  fossa,  and  a  discrete  rose-eolored  eruption  upon  the  chest 
and  belly.  Convalescence  at  the  beginning  of  the  third  week ;  disease 
generally  continues  about  four  weeks. 

THE  OPHTHALMOSCOPE  IN  NERVOUS  DISORDERS. 

In  the  diagnosis  of  intracranial  disorders  the  ophthalmoscope  is  often 
of  great  service,  though,  perhaps,  scarcely  to  the  extent  advocated  by 
Bouchut.  The  discrete  tubercles  of  the  choroid  accompanying  meningeal 
deposit,  the  choked  disc  in  cerebral  tumors  and  inflammations,  and  the  reti- 
nitis and  retinal  hemorrhages  of  Bright's  disease,  are  of  great  importance. 
Bouchut  declares*  that  the  ophthalmoscope  is  as  indispensable  to  the 
physician  as  to  the  oculist,  and  he  was  among  the  first  to  point  out  the 
great  importance  of  this  aid  to  practical  medicine.  We  quote  his  opinions 
and  conclusions: — 

"  All  diseases  of  the  brain  and  spinal  cord,  and  all  the  nervous  affec- 
tions termed  neuroses,  because  they  are  regarded  rather  as  functional  than 
organic,  ought  to  be  investigated  by  its  aid.  When'  by  its  assistance  the 
physician  discovers  a  lesion  of  the  optic  nerve,  of  the  retina,  or  of  the 
choroid,  in  a  case  presenting  convulsive,  choreic,  paralytic,  or  spasmodic 
nervous  phenomena,  he  may  be  certain  that  a  cerebro-spinal  lesion  is  the 
starting-point  of  these  symptoms.  Every  symptom  regarded  as  nervous, 
which  is  accompanied  by  a  lesion  of  the  fundus  of  the  eye,  is  caused  by 
an  organic  alteration  of  the  brain,  the  cord,  or  the  membranes.  Thus  is 
it  with  chorea,  considered  by  many  physicians  as  a  simple  neurosis ;  and 
yet  this  should,  in  consequence  of  the  congestive  optic  neuritis  found  in 
its  subjects,  be  regarded  as  a  congestive  affection  of  the  anterior  spinal 
columns.  So  also  epilepsy,  in  a  certain  number  of  cases,  is  the  result  of 
cerebro-spinal  lesions  which  at  the  same  time  induce  changes  in  the  optic 
nerve  or  retina.  Hysterical  paraplegia  and  paralysis  produce  no  neuro- 
retinian  changes,  while  symptomatic  paraplegia  and  spinal  ataxia  pro- 
duce either  simple  hyperemia  of  the  optic  nerve  or  hyperemia  and 
atrophy.  So  leucaemic,  tubercular,  glycosuric,  or  albuminuric  diatheses 
*  "Revue  Cerebroscopique,"  in  Gazette  des  Hupitaux,  for  January,  1874. 


DISEASES   OF  THE    NERVOUS   SYSTEM.  81 

are  often  revealed  by  optic  neuritis,  the  ophthalmoscopic  diagnosis  in  some 
of  these  cases  being  most  striking.  It  is  especially  in  patients  attack'' I 
by  general  acute  tuberculosis,  accompanied  by  typhoid  symptoms,  and 
which  are  mistaken  for  typhoid  fever,  that  cerebroscopy  becomes  truly 
remarkable.  In  an  infant  in  whom  the  disease  had  all  the  appearance  of 
typhus,  the  ophthalmoscope,  by  revealing  tubercles  of  the  choroid  with 
neuro-retinitis,  determined  that  there  were  tubercles  in  the  brain,  and 
consequently  productions  of  the  same  character  all  over  the  body — which 
the  autopsy  demonstrated  to  be  the  fact. 

"Can  any  diagnosis  be  more  exact  than  this?  You  see,  in  the  living 
man,  tubercles  of  an  organ  which  permit  you  to  conclude  that  they  will 
also  be  found  elsewhere.  You  see  a  nerve  either  healthy  or  diseased,  and 
this  indicates  whether  its  roots  are  sound  or  diseased;  and  you  have 
almost  laid  bare  arteries  and  nerves  which  are  so  afferent  to  the  brain  that 
changes  in  them,  studied  with  care,  represent  similar  changes  in  a  portion 
of  the  nervous  centres.  It  seems  almost  marvelous;  and  I  do  not  think 
that  since  auscultation  there  has  been  anything  discovered  so  useful  to 
semeiology.  Henceforth,  the  physician  may  divine  and  often  affirm 
lesions  of  the  brain,  cord,  or  meninges,  the  diagnosis  of  which  before  was 
impossible  or  only  probable.  Thus:  1.  From  hypersemia  and  hyper- 
aemic  tumefaction  of  the  optic  nerve  there  results  the  diagnosis  of  me- 
chanical or  inflammatory  hypersemia  of  the  brain  in  meningitis,  in  cere- 
bral hemorrhage,  effusions  into  the  brain,  and  in  some  cases  the  diagnosis 
of  ataxic  or  other  spinal  diseases.  2.  By  papillary  oedema  joined  to 
hyperaemia  I  recognize  oedema  of  the  meninges ;  or  an  obstructed  cerebral 
circulation  through  meningitis,  cerebral  tumors,  ventricular  hydroceph- 
alus, cerebral  hemorrhage,  meningeal  effusions,  thrombosis  of  the  sinus, 
etc.  3.  By  neuro-retinian  and  choroidean  anaemia,  I  recognize  cerebral 
hemorrhage  of  ramollissement,  and  if  the  anaemia  be  absolute  it  is  fatal. 
Empty  arteries  and  veins  of  the  eye,  and  an  exsanguineous  condition  of 
the  choroidean  network,  indicate  arrest  of  cerebral  and  cardiac  circulation. 
4.  By  exudative  and  fatty  optic  neuro-retinitis,  I  recognize  chronic  rne- 
ningo-cephalitis ;  the  encephalitis  of  cerebral  tumors,  and  the  changes  in 
the  nervous  substance  which  accompany  these  tumors.  5.  By  retinian 
varices  and  thromboses,  I  distinguish  meningeal  thromboses,  or  those  of 
the  sinuses.     6.  By  the  aneurisms  of  the  retinian  arteries  we  may  recog- 


82  DIFFERENTIAL   DIAGNOSIS. 

ni/.c  the  miliary  aneurism.-  of  the  brain.  7.  By  simple  retinian  hemor- 
rhages we  recognize  a  compression  of  the  brain  by  hemorrhagic  or  other 
effusions;  but  if  those  retinian  hemorrhages  are  accompanied  Iry  retinian 
steatosis,  there  is  also  cerebral  steatosis,  and  this  is  the  ease  in  chronic 
albuminuria,  leucocythsemia,  and  glycosuria.  8.  By  atrophy  of  the  opt  ie 
nerve,  tumors  of  the  brain  and  cerebral  or  spinal  sclerosis  are  discovered. 
9.  Finally,  we  never  meet  with  tubercular  granulations  in  the  choroid 
without  the  existence  of  similar  ones  in  the  lungs  or  other  organs.* 

The  ophthalmoscope  is  now  frequently  employed  for  diagnostic  pur- 
poses in  ordinary  medical  practice  where  there  is  imperfection  of  vision, 
to  determine  whether  it  is  due  to  other  than  nervous  lesions,  to  discrimi- 
nate between  affections  of  different  portions  of  the  eye,  and,  sometimes,  to 
measure  the  amount  of  refraction  in  cases  of  hypermetropia  and  myopia. 
Even  where  there  is  no  impairment  of  sight,  there  still  may  occur  very 
decided  and  characteristic  retinal  changes  and  alterations  in  the  optic  disc, 
which  are  readily  detected  by  ophthalmoscopic  examination,  as  already 
indicated;  so  that  in  obscure  cases  the  routine  examination  of  the  eyes 
has  become  nearly  as  imperative  as  the  chemical  and  microscopical  exam- 
ination of  the  urine. 

HEADACHE. 

Some  of  the  most  trying  cases  to  treat  are  those  of  headache,  because 
this  symptom  may  appear  in  many  and  even  diverse  morbid  states,  and 
often  indicates  serious  cerebral  disorder.  Mr.  Wm.  Henry  Day,  of 
London,t  has  made  a  study  of  these  conditions,  and  thus  summarizes  his 
conclusions : — 

Headache  usually  denotes  some  functional  disturbance  of  the  brain  or 
its  membranes,  induced  (1)  by  excess  of  local  blood  pressure,  (2)  by 
absorption  into  the  blood  of  poisonous  matters,  (3)  or  by  such  a  diminution 
of  healthy  blood  as  provokes  irritation  and  suffering.  It  may  be  a 
svmptom  of  organic  disease,  either  of  the  brain  or  its  membranes,  or  of 
the  kidneys  or  stomach,  and  uterus. 

Cerebral  anosmia. — A  striking  symptom  is  pain  at  the  top  of  the  head, 
which  often  feels   hot  and  burning,  sometimes  gnawing  and  scraping.. 

*  Medical  Times  and  Gazette,  January  23,  187-5. 
f  British  Medical  Journal,  Nov.  16th,  1878. 


DISEASES    OF  THE    NERVOUS   SYSTEM.  83 

Irritability  of  temper.     Face  livid  and  cold.     Patient  easily  exhausted. 
Eyes  dull. 

Plypercemia,  Active  or  Passive — Active. — Arterial  fullness.  Head  hot, 
pain  frontal,  throbbing  and  bursting,  pulse  tense,  full.  Conjunctiva;  red- 
dened.  Eyes  bright.   Photophobia.   Mentality  dull.   Apoplexy  may  ensue. 

Passive. — Venous  fullness  from  obstruction  caused  by  heart  disease, 
bronchocele,  etc.,  pleuritic  effusion,  defective  ventricular  action. 

Sympathetic  headache. — Faulty  digestion  or  ovarian  excitement. 
Stomach  sometimes  weak  and  over-sensitive.  Catamenial  headache. 
Dyspeptic  and  bilious  headache.  Irritation  of  the  sympathetic  reduces 
the  amount  of  blood  in  (he  brain. 

Nervous  headache. — Disturbance  of  brain  from  overwork,  worry  and 
anxiety.  Aggravated  by  some  of  the  circumstances  favoring  sympathetic 
headache.  In  women  there  is  a  passage  of  a  large  quantity  of  limpid 
urine  ;  feet  and  hands  cold.  Confusion  of  ideas.  Nausea  and  sickness, 
not  attributable  to  errors  in  diet,  may  precede  the  attack.  In  nervous 
people  constipation  may  cause  headache. 

Poor  seamstress  headache. — Spansemia.  Headache  of  excessive  men- 
struation, or  menorrhagia.     Hereditary  influence  strong. 

Neuralgic  headache. — From  decayed  teeth,  peripheral  irritation,  ma- 
larial poison.  Pain  and  tenderness  along  the  fifth  nerve.  Pain  intense  ; 
not  relieved  by  vomiting. 

Toxcemic  headache. — Poisoned  blood  acting  on  nerve  centres,  from 
particular  articles  of  food  or  drink,  and  drugs.  Or  certain  specific 
diseases — gout,  rheumatism  and  syphilis.  Headache  of  vitiated  atmos- 
phere. 

Organic  headache. — Morbid  growths ;  meningitis.  When  slowlv 
progressing  pain  is  limited  to  smaller  area,  and  is  intense.  Periosteal  in- 
flammation is  accompanied  by  tenderness  upon  pressure. 

Headache  in  children,  due  to  accidental  injuries,  to  derangement  of 
alimentary  canal,  anaemia,  exhausting  influences,  such  as  bad  food  and 
impure  air,  immoderate  intellectual  efforts,  and  sometimes  to  organic 
diseases  (often  tuberculosis). 

In  strumous  and  weakly  children  headache  must  be  carefully  watched. 
A  headache  of  long  standing  in  a  child  is  significant,  and  requires  more 
serious  attention  than  in  the  adult. 


-I 


DIFFKRKXTIAT.    1  'I  A<  JNOSIS. 


CHRONIC  CEREBRAL  DISORDERS. 

In  children  the  diagnosis  may  be  required  to  he  made  between  hyper- 
trophy of  the  braiD  and  hydrocephalus,  which  have  enlargement  of  the 

head  as  a  common  sign. 


HYPERTROPHY. 

Increase   in    size    most   marked 
above  the  superciliary  ridges. 

Head  square  in  shape. 

No    yielding    of    fontanelle    on 
pressure. 

Eyes  at  normal  distance. 

Excessive   amount  of  brain,  es- 
pecially white  matter. 

Patient   dull,  liable   to  epileptic 
fits,  and  suffers  from  headache. 


HYDROCEPHALUS. 

Increase  in  size  most  marked  at 
the  temples. 

Head  more  rounded. 

Fontanelle  elastic. 

Distance  between  the  eyes  in- 
creased. 

Excessive  amount  of  fluid  in 
ventricles,  or  sub-arachnoid  space. 

Mentality  feeble;  generally  can 
be  traced  to  congenital  source ;  death 
may  occur  from  convulsions.  No 
marked  headache. 


The  diagnosis  of  hydrocephalus  may  be  confirmed  by  tapping  the 
fontanelle  with  the  aspirator,  or  a  hypodermic  syringe.  In  adults  brain 
tumor  and  sclerosis  are  among  the  prominent  disorders  of  slow  progress, 
the  symptoms  varying  in  a  very  marked  manner  with  the  location  of  the 
lesion.  Chronic  inflammation  of  the  brain  may  terminate  in  insanity  or 
in  abscess.  In  its  course  it  has  been  mistaken  for  dyspepsia,  but  a  proper 
inquiry  into  the  mental  condition  of  the  patient  will  reveal  the  cerebral 
mischief,  which  continues  to  progress  even  after  any  coexisting  indigestion 
has  been  corrected.  There  is,  moreover,  sluggish  intelligence,  and  partial 
paralysis  or  rigidity  of  certain  muscles  of  the  extremities.  Attacks  of 
delirium  or  mania  finally  confirm  the  diagnosis,  and  the  patient  dies  in 
a  state  of  coma. 

Intra-cranial  disease  of  a  chronic  character  is  often  so  obscure  as  to 
leave  even  the  most  experienced  in  doubt,  and  the  post-mortem  examina- 
tion sometimes  produces  revelations  that  disconcert  the  medical  attendant, 
Due  regard  to  some  of  the  characteristic  phenomena  in  the  accompanying 
table  will  often  serve  to  clear  up  the  doubts  surrounding  a  difficult  case. 


DISEASES    OF  THE   NERVOUS  SYSTEM. 


85 


BRAIN  TUMOR.  SOFTENING 

(WHITE). 
Of    slow    develop-i     Approach  and  pro- 
ment.  gress  Blow.    Follows 

embolism  or  apo- 
plexy. Non-inflam- 
matory. 


Intellect    not    dis- 
ordered at  first. 


Headache  violent, 
paroxysmal  and  often 
localized. 

Paralysis  slow  in 
appearing,  and  often 
limited  to  the  mus- 
cles of  eye  or  of  the 
face ;  more  rarely 
hemiplegia. 


Convulsions  a  com- 
mon symptom,  epi- 
leptiform in  charac- 
ter. Not  followed  by 
palsy  or  hebetude. 

Vertigo  and  tinni- 
tus auriuni. 


Early  affection  of 
intelligence.  Marked 
impairment  of  mem- 
ory. 

Dull  and  constant. 


Motor  and  senBor 
phenomena  more 
frequent  and  promi- 
nent. Partial  palsies 
and  disturbances  of 
sensibility  subse- 
quently. 

Begins  often  with 
apoplectiform       at- 


ABSCESS. 

Follows  injury  to 
the  skull  or  chronic 
disease  of  the  head. 


Varies  with  seat. 


Sudden  in  its  de- 
velopment, and  gen- 
eral. 

Course  is  much 
more  rapid  :  con- 
vulsions, drowsi- 
ness, paralysis  and 
coma  quickly  de- 
veloped. 


Con  vulsio  ns 
early;  paralysisbe- 


Vomiting. 


tacks,  which  seldom  .longs  to  developed 
occur  afterward.  stage. 


Vertigo. 


Not  unfrequently.       Rare, 


CHBONIC  THROMBOSIS  OF 

MENINGITIS.       SINUSES  OT  BBA I  NT. 
Caused  by  syphilis,      S  u  <1  d  e  n   develop- 

rheumatism,   disease  mentof  symptoms, 
of  bones,  blows  upon 
the  head,  etc. 


Intelligence  not  af- 
fected, except  during 
attacks  of  delirium. 


Subj  ect  to  exacerba- 
tions, but  generally 
chronic. 


In  consequence  of 
meningeal  exudation 
may  present  the  clini- 
cal signs  of  a  brain 
tumor. 


More  vertigo. 


Frequentvomiting.      No  vomiting 


May  be  uncon- 
sciousness or  not.  In- 
telligence subse- 
quently good. 

No  headache ;  oede- 
ma of  forehead  and 
eyelids. 

May  be  coma ;  va- 
ries greatly,  accord- 
ing  to  part  of  brain 
whose  vascular  snp- 
ply  is  disturbed. 


Very  rare. 


SCLEROSIS. 

Sclerosis  is  a  disease  of  the  nerve  centres,  in  which  there  is  increase  of 
connective  tissue  elements,  without  primary  involvement  of  the  nerve 
cells.  It  may  exist  as  diffused  cerebral  sclerosis,  spinal  sclerosis  (several 
forms),  cerebro-spinal  sclerosis  (sclerose  en  plaque),  and  glosso-labio- 
laryngeal  paralysis.  Cerebral  sclerosis  occurring  in  children  can  be 
distinguished  from  deficient  development  by  the  following  character- 
istics : — 

DEFECTIVE  DEVELOPMENT  OF 
INTELLIGENCE. 

Intelligence  stationary,  instead  of 
progressing  with  age. 

Not  connected  with  disease. 


DIFFUSED  CEREBRAL  SCLEROSIS. 


Speech   restricted  to  few  words, 
imperfectly  pronounced. 


retrogressive     and 
Often  terminates  in 


Intelligence 
more  affected, 
idiocy. 

May  follow  injury  to  head,  zy- 
motic fevers,  severe  application  of 
body  or  mind. 

Never  learns  to  talk,  or  speech 
becomes  imperfect  or  lost  after  it 
has  been  acquired. 


$6 


DIFFERENTIAL    DIAGNOSIS. 


DEFECTIVE  DEVELOPMENT  OF 
INTELLIGENCE. 

No  paralyses. 

Muscular  system  in  good  condi- 
tion. 

No  convulsions. 

Improved  by  training  and  educa- 
tion. 


DIFFUSED  CEREBRAL  SCLEROSIS. 

Usually  more  or  less  hemiplegia. 

Arrest  of  growth  of  certain  parts 
of  body,  with  contraction  and  dis- 
tortion of  affected  limbs. 

Frequent  convulsions. 

Progress  very  chronic,  and  may 
live  to  advanced  age. 


LOCALIZATION  OF  BRAIN  DISEASE. 

The  localization  of  diseases  of  the  brain  is  a  subject  of  great  interest. 
In  order  that  a  correct  diagnosis  should  be  made  the  important  anatomical 
and  physiological  data  must  ever  be  borne  in  mind.  We  proceed  first  to 
the  consideration  of 

LESIONS  OF  THE  CEREBRAL  CORTEX. 

[The  accompanying  excellent  diagram,  or  physiological  map  of  the 
principal  cerebral  cortical  centres,  modified  from  Ferrier  and  Ecker, 


CORTICAL  CENTRES  OF  THE  IIVMAN  J1RAIN. 


A,  Ascending  frontal  gyrus; 
lesions  which 


S,  Fissure  of  Silvius;  c,  Fissure  of  Rolando;  po,  Paricto-occipital  fissure.  A,  Ascending 
B,  Ascending  parietal  gyrus;  F3,  Third  frontal  gyrus;  P./,  Gyrus  angularis.  Circle  I,  Seat  of 
(on  the  left  aide)  cause  aphasia.  Circle  II,  Seat  of  lesions  which  convulse  or  paralyze  the  upper  extremity  of 
the  opposite  side.  Dotted  Circle  III,  Seat  of  lesions  which  probably  convulse  or  paralyze  the  face  on  tho 
opposite  side.  Dotted  Oval  IV,  Seat  of  lesions  which  probably  convulse  or  paralyze  the  lower  extremity  of  tho 
opposite  side.  These  districts  receive  their  blood  supply  chiefly  from  the  middle  cerebral  artery.  The  re- 
maining letters  refer  to  anatomical  points  which  explain  themselves. 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


87 


by  Seguin,  will  be  found  very  useful,  as  it  embodies  the  results  of  the 
recent   researches   of  Fritsch   and   Hitsig,   Ferrier,  Daltox   and 
Seguin;*  particularly  as  this  subject  is  now  attracting  much  attention.] 
The  following  is  the  summary  given  by  Seguin  (Joe.  cit.) : — 


PHYSIOLOGICAL. 

"  In  the  first  place,  it  appears  al- 
most absolutely  certain  that  in  man 
a  lesion  involving  the  posterior  part 
of  the  third  frontal  convolution  (on 
the  left  side  usually)  causes  aphasia; 
i.e.  impairment  or  loss  of  articulate 
speech,  or  even  of  language  in  gene- 
ral. It  would  seem,  besides,  that 
(1)  lesions  of  the  same  part  on  either 
side  of  the  brain  produce  paresis  of 
many  muscles  concerned  in  lingual 
and  pharyngeal  movements;  (2) 
that  lesions  of  the  anterior  folds  of 
the  island  of  Reil  (convolutions 
which  are  continuous  with  the  third 
frontal),  may  also  produce  aphasia  ; 
and  that  (3)  loss  of  speech  may  re- 
sult from  injury  to  the  white  sub- 
stance lying  between  the  third  front- 
al gyrus  and  the  basis  cerebri.  I 
believe  in  a  not  too  limited  localiza- 
tion of  the  motor  functions  exerted 
in  language,  and  would  graphically 
represent  this  by  the  circle  marked 
I. 

"  In  the  second  place,  lesions 
limited  to  the  inferior  portions  of 
the  ascending  frontal  and  parietal 
gyri  have  produced  spasmodic  and 
paralytic  phenomena  limited  to  the 
upper  extremity  of  the  opposite  side. 
I  am  disposed  to  admit  as  highly 
probable  that  these  parts  are  con- 
nected in  the  healthy  living    man 

*  See  Lectures  in  New  York  Medical  Record,  delivered  at  the  College  of  Physicians 
and  Surgeons,  New  York,  in  January,  1878. 


PATHOLOGICAL. 

"  1.  The  symptoms  of  an  irritative 
lesion  of  these  parts  consist  in  con- 
vulsions, with  or  without  subsequent 
transient  paralysis ;  e.  g.,  such  a 
lesion  in  circle  III  would  give  rise 
to  spasmodic  movements  in  the  su- 
perficial muscles  of  the  face  on  the 
opposite  side,  with  slight  paralysis. 
Irritative  lesions  of  the  regions  in- 
closed in  circles  II  and  IV  will 
cause  convulsions  limited  to,  or  first 
appearing  in  the  hand  and  arm,  or 
foot  and  leg,  of  the  opposite  sides. 
As  regards  circle  I  (Broca's  speech 
centre),  we  know  little  of  the  effects 
of  its  pathological  irritation.  In 
one  case  which  I  have  placed  on 
record,  a  thickening  of  the  meninges 
involving  the  third  frontal  convolu- 
tion of  the  left  side  produced  inter- 
mittent and  incomplete  aphasia. 

"  It  was  by  the  close  study  of  the 
clinical  and  pathological  aspects  of 
cases  of  localized  epilepsy  (fingers 
and  hands),  that  Dr.  J.  Hughlings 
Jackson  was  enabled  to  form  his 
theory  of  motorial  discharges  from 
irritation  of  the  cortex  cerebri,  and 
thus  pave  the  way  for  Ferrier's 
admirable  researches.  Dr.  Jackson 
must,  I  think,  be  considered,  after 
Prof.  Broca,  as  the  founder  of  our 
present  growing  doctrine  of  cortical 
localizations. 


88 


DIFFERENTIAL   DIAGNOSIS. 


PHYSIOLOGICAL.  PATHOLOGICAL. 

with  the  various  voluntary  move- 1  "  2.  Destructive  lesions  of  portions 
incuts  of  the  arm  and  hand.  This  of  the  excitable  district  produce 
zone  is  represented  by  circle  II.  j  paralysis  in  peripheral  parte  across 
"  I  am  not  prepared  to  go  further  the  median  line.  The  symptoms 
in  admitting-  pathologically  proved  |  will,  to  a  certain  extent,  correspond 
cortical  centres,  but  would  add  that  with  the  precise  location  of  the  le- 
t  lure  are  some  reasons  for  believing!  sions,  very  much  as  in  irritative 
that  future  autopsies  will  locate  one   lesions;    e.g.,  embolism   of  the  first 


centre  for  the  external  facial  muscles 
just  forward  of  the  two  centres 
named  above,  viz.,  the  region  in- 
cluded in  the  dotted  circle  III ; 
and  another  for  movements  of  the 
legs  upon  the  upper  parts  of  the  as- 
cending frontal  and  parietal,  as 
indicated   by  dotted    oval 


roughly 
IV." 


branch  of  the  middle  cerebral  artery 
on  the  left  side  will  cause  softening 
of  the  posterior  part  of  the  third 
frontal  gyrus,  with  the  symptom 
aphasia.  A  destructive  lesion  of  the 
principal  part  of  the  motor  zone  on 
the  right  side  will  produce  left 
hemiplegia  without  aphasia;  but  if 
this  lesion  occupy  the  left  hemi- 
sphere, loss  of  speech  will  co-exist 
with  the  paralysis." 

It  must  be  added  that  secondary  descending  degeneration  ensues  after 
destructive  lesions  of  the  motor  regions  of  the  cortex,  and  that  we  have 
late  contracture  or  rigidity  of  the  paralyzed  limbs  as  part  of  the  symptom 
group. 

Negative  characters  of  these  cortical  lesions  are  preservation  of  sensi- 
bility in  the  paralyzed  parts,  and  (except  with  epileptic  attacks)  preser- 
vation of  consciousness,  and  incompleteness  of  paralysis. 

In  diffused  lesions  of  the  cortex  the  chief  symptoms  are  delirium, 
convulsions  and  pain ;  evidences  of  intense  irritation.  The  coma  and 
paralysis  which  follow  may  in  some  degree  be  caused  by  impaired  nutri- 
tion of  the  cortex,  but  more  probably  by  circulatory  and  tension  changes 
in  the  whole  encephalic  mass. 

As  regards  sensory  cortical  centres,  Dr.  Seguin  believes  that  we  have  as 
yet  no  pathological  data  for  their  study. 

DISEASE  OF  BRAIN  CENTRES  OTHER  THAN  CORTICAL. 

The  following  tabular  view  of  the  paralyses,  with  the  localization  of 
the  lesion,  is  mainly  that  of  Professor  DaCosta.* 

*  "  Medical  Diagnosis,"  4th  Edition,  Philadelphia,  1876. 


DISEASES   OF   THE   NERVOUS  SYSTEM. 


89 


SYMPTOMS. 

Hemiplegia,  without  disturbance 
of  sensation.  Incomplete  paralysis 
of  face.  Electro-muscular  contract- 
ility normal  or  increased.  Gener- 
ally accompanied  by  apoplectic 
symptoms. 

Crossed  paralysis  (i.e.  face  of  right 
and  hemiplegia  of  left,  or  vice  versa). 
Paralysis  of  face  marked,  both  of 
motion  and  sensation.  General 
symptoms  giddiness,  nausea. 

Same  as  above,  except  complete 
facial  paralysis  (both  sides  of  face). 

Paralysis  of  arm  and  leg,  slight 
paralysis  of  face,  dilatation  of  pupil 
of  opposite  side,  with  external  squint 
(3d  nerve  paralysis). 

General  paralysis,  more  or  less 
complete;  sensation  diminished 
upon  one  side,  increased  upon  the 
other.  Local  temperature  varia- 
tions. 

As  regards  the  side  of  the  brain  aifected,  certain  peculiarities  have  been 
noted  by  able  observers. 


SEAT  OF  LESION. 

In  corpus  striatum,  near  the  in- 
ternal capsule ;  on  side  opposite  to 
hemiplegia. 


Pons  Varolii  upon  opposite  side 
to  palsy  of  limbs  (below  decussation 
of  facial  nerve). 


Pons  at  level  of  decussation  of 
facial  nerve. 

Crus  cerebri  on  side  correspond- 
ing with  affected  eye. 


Medulla  oblongata  on  side  of  in- 
creased sensibility  and  temperature, 
at  the  level  of  decussation  of  ante- 
rior pyramids. 


LESIONS  OF  THE  RIGHT  HEMISPHERE. 

Anaesthesia  more  complete. 
Paralysis  more  complete. 

Paralysis  of  sphincters. 

Alterations  of  nutrition  (oedema, 
eschars,  fevers,  pulmonary  conges- 
tion). 

Disorders  of  special  senses. 

Hysterical  symptoms. 


LESIONS  OF  THE  LEFT  HEMISPHERE. 

Loss  of  speech  (aphasia). 

Paralysis  of  muscles  of  articula- 
tion. 

Less  marked. 

Less  marked. 


Less  marked. 
Hysteria  seldom. 


The  observations  of  Brown  Sequard  have  demonstrated  that  in  excep- 
tional cases  the  symptoms  do  not  correspond  as  accurately  with  the 


90 


IM FFEKEXTIAL    DIAGNOSIS. 


anatomical  position  of  the  lesion  as  is  above  indicated.  At  the  present 
time  these  cases  must  be  looked  upon  as  really  exceptional,  and  as  not 
affecting  the  rules  which  have  just  been  cited.  More  particularly  are 
these  aberrant  symptoms  likely  to  appear  in  tubercular  disease  of  the 
brain.  Indeed,  Prof.  Henoch  (in  CharitP  Annalen,  fourth  year),  reports 
nine  cases  of  tuberculosis  of  the  brain  that  show  how  risky  it  is  to 
localize,  basing  this  upon  recent  physiological  investigations.  The  results 
are  as  follows: — 


SYMPTOMS. 
Case  I. — Left  hemiplegia. 


Case  II. — Tremor  and  paresis  of 
the  right  side,  finally,  contraction 
of  all  extremities. 

Case  III. — Hemiplegia  and  con- 
tracture of  the  left  side,  as  well  as 
of  the  facial  nerve. 

Case  IV. — Contracture  and  in- 
voluntary motion  on  right  half  of 
face  and  body. 

Case  V. — Complete  absence  of 
symptoms  uutil  meningitis  set  in. 

Case  VI.— Paralysis  of  the  left 
abducens,  the  left  iris  and  right  arm. 

Case  VII. — Absence  until  men- 
ingitis set  in. 

Case  VIII. — Complete  absence. 

Case  IX. — Paralysis  of  the  right 
abducens. 


LESION. 

Multiple  tubercles  of  the  cortical 
layer  of  both  hemispheres,  the 
frontal  lobes  and  tubercle  of  the 
left  half  of  the  cerebellum. 

Tubercle  of  the  left  frontal  lobe, 
the  left  corpus  striatum,  both  tha- 
lami  and  right  half  of  the  cerebel- 
lum. 

Tuberculosis  of  the  right  frontal 
lobe. 

Tuberculosis  of  the  left  frontal 
lobe. 

Tuberculosis  of  the  commissure 
of  the  cerebellum  and  of  both  hem- 
ispheres. 

Tuberculosis  of  the  commissure 
of  the  cerebellum. 

Tubercle  in  the  pons. 

Tubercle  of  the  left  posterior  lobe. 

Tuberculosis  of  both  posterior 
lobes,  the  posterior  corpora  quadri- 
gemina,  the  pons  and  left  crus  cere- 
belli. 


Of  all    these  cases  only  II  and  III  show  the  possibility  that  lesions 
of  the  motoric  centre  of  the  frontal  convolutions  produce  motoric  lesions 


DISEASES   OF   THE    NERVOUS   SYSTEM.  91 

of  the  opposite  side.  This  chance  of  diagnosis,  however,  is  very  limited, 
as  is  shown  by  the  other  cases  where  these  locations  were  free  from  dis- 
ease, and  yet  the  same  symptoms  produced  with  lesions  in  other  parts  of 
the  brain,  even  cerebellum  (Case  VI).  Sometimes  the  intensity  of  the 
symptoms  does  not  seem  to  correspond  with  the  intensity  of  the  lesion 
(V  and  VI).  Henoch  believes  that  a  close  study  of  the  fibres  leading 
from  and  to  these  physiological  centres  will  do  much  to  reconcile  the 
apparent  contradictions  between  pathological  and  symptomatological 
differences.* 

The  subject  of  insanity  will  be  separately  considered  at  the  end  of  this 
section. 

SPINAL  DISEASES. 

A  leading  symptom  of  many  diseases  of  the  spinal  cord,  whether 
functional  or  organic,  is  paraplegia.  It  is  so  rarely  of  cerebral  origin 
that  ordinarily  the  brain  may  be  omitted  from  the  discussion,  unless  there 
is  the  co-existence  of  distinct  evidences  of  brain  disease,  as  headache, 
impaired  cerebration,  and  paralysis  of  parts  supplied  by  nerves  arising 
above  the  spinal  cord. 

The  following  classification  of  diseases  giving  rise  to  paraplegia,  with 
their  characters,  has  been  proposed  by  Prof.  H.  C.  WooD.f 


Disease  of  the  cord. 


FUNCTIONAL.  HYSTERICAL. 

Anaemic.  Hysteria. 

Reflex  (from  peripheral 
irritation,  renal,  preputial, 
etc.). 

Dyscrasic  (diphtheritic, 
etc.). 

The  last  mentioned,  hysterical,  is  also  functional,  but  simulates  the 
organic  more  closely  than  does  the  second  group.  (For  further  consider- 
ation of  Hysterical  Paralysis,  see  Hysteria.)  It  must  be  admitted,  how- 
ever, that  so-called  functional  disorder  cannot  long  exist  without  being 
followed  by  change  in  structure. 

The  general  distinctions  between  the  organic  and  functional  paraplegias 
may  be  presented  as  follows  : — 

*  Cincinnati  Lancet  and  Clinic,  May  31,  1878. 

f  "  On  the  Diagnosis  of  Diseases  accompanied  by  Paraplegia."     1875. 


92 


DIFFERENTIAL   DIAGNOSIS. 


ORGANIC. 

Onset  may  be  almost  instanta- 
neous or  very  rapid,  though  some- 
times gradual. 

Usually  at  some  period  spasm  or 
pain  in  the  affected  limbs. 

Often  a  sensation  of  a  band  or 
stricture  around  the  waist,  girdle- 
pain  (pathognomonic). 

Anaesthesia  frequent  and  often 
complete. 

Retardation  of  sensation  (a  per- 
ceptible time  elapses  between  the 
patient's  seeing  his  feet  touched  and 
feeling  that  they  are)  (pathogno- 
monic). 

Symptoms  of  paralysis  of  the 
bladder. 


FUNCTIONAL. 

The  onset  always  more  or  less 
gradual,  except  the  hysterical  form, 
where  the  paralysis  is  generally 
abrupt. 

Spasms  or  pain  rarely  or  never 
present. 

Not  found. 


Anaesthesia  absent  or  but  partial. 

Sensation,  if  present  at  all,  is  not 
retarded. 


No  symptoms  whatever  of  vesical 
paralysis,  except  in  the  hysterical 
form. 

Where  the  bony  canal  is  involved  and  caries  is  present,  this  condition 
may  generally  be  discovered  by  Rosenthal's  test.  This  consists  in 
passing  down  the  back  a  pair  of  electrodes  attached  to  a  faradaic  battery 
of  some  power,  one  pole  being  placed  upon  each  side  of  the  spine.  Under 
these  circumstances  if  there  be  any  caries  or  inflammation  of  the  verte- 
bra?, the  moment  its  locality  is  reached  the  patient  starts  or  screams,  from 
the  burning,  sticking  pain  caused  by  the  passage  of  the  galvanic  current 
through  the  inflamed  tissue.  Dr.  Wood  states  he  has  not  found  this  test 
as  trustworthy  as  its  originator  claimed  it  to  be,  and  as,  apparently,  it 
ought  to  be.  In  cases  simulating  caries,  however,  the  pain  is  probably 
not  so  severe  as  where  the  vertebrae  are  really  affected.  Moreover, 
absence  of  the  pain  in  any  case  seems  to  be  conclusive  evidence  of  the 
non-existence  of  bone  disease. 

The  following  study  of  the  principal  organic  spinal  diseases,  from  the 
writings  of  Seguin,  Charcot  and  other  authorities,  when  taken  in 
conjunction  with  the  tabular  view  of  paralysis,  will  often  enable  the 
diagnostician  to  determine  both  the  nature  and  location  of  a  spinal 
lesion  : — 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


93 


DISEASES  OP  SPINAL  CORD. 

m „„„„„„  j-«-,„„j  „  .  «•*•„  , t„  „„j  „u„ i„\  f  occupying  the  entire  section  of  a  limited  portion  of  the 

Transverse  diffused  myelitis  (acute  and  chronic)  j     ^  ^  or  legg  coml,,etely- 

{(■Patches  of  disease  situated  primarily  in  the  connective   I 
Disseminated  sclerosis   (sclerose  en  pldques).<     and  scattered  without  regard  to  the  "systematic"   grouping 
(^    of  the  nervous  elements. 
Its  distribution   is    "  sys- 
tematic," and,  probably, 
it  is  essentially  a  primary 
disease  of  the  nerve  ele- 
ments lather i han  of  the 
connective  tissue. 
("Ditto,  though   its    pathology  is  as    yet   almost 
-<      purely  a  matter  of  inference.     Its  characteristic 
(.     symptom  is  muscular  rigidity, 


Degenerative  disorders, 
mainly  affecting  ihe 
columns  of  the  cord. 


Symmetrical  lateral  sclerosis. 
(Paralysis  spinalis  spastica.) 


f  Poliomyeltis  anterior. 


Myelitis  of  the  gray 
matter  of  the  anter-< 
ior  cornua. 


Antero-lateral  sclerosis 
(amyotrophic). 


1  Acute. 
Subacute. 
Chronic. 


/Infantile  paralysis. 

^  Acute  spinal  paralysis  of  the  adult. 


f  Often  classified  as  a  special  form  of  po- 
liomyelitis chronica,  but  characterized 
by  the  absence  of  paralysis,  except 
such  as  is  directly  due  to  the  muscular 
atrophy. 

Not  yet  thoroughly  studied,  but  believed  by  Charcot  and  others  to  involve  at 
once  the  lateral  columns  and  the  anterior  cornua  ;  the  characteristic  symptoms 
being  atrophy  with  contracture,  beginning  in  the  upper  extremities. 


Progressive  muscular  atrophy  and  pro 
gressive  bulbar  paralysis  ("  labio 
glossopharyngeal  paralysis"). 


TABULAR  VIEW  OF  SPINAL  PARALYSIS. 


SYMPTOMS. 

Paralysis  of  compressor  urethrse, 
accelerator  urinse  and  sphincter  ani. 
No  paralysis  of  muscles  of  the  legs. 

Paralysis  of  muscles  of  bladder, 
rectum  and  anus.  Loss  of  sensation 
and  motion  in  muscles  of  legs,  ex- 
cept those  supplied  by  anterior  cru- 
ral and  obturator  (viz.,  psoas  iliacus, 
sartorius  pectineus,  three  adduc- 
tors, obturator  externus,  two  vasti, 
rectus  femoris,  etc.). 

Both  legs  paralyzed  as  to  sensa- 
tion and  motion.  Loss  of  power 
over  bladder  and  rectum.  Lateral 
muscular  walls  of  abdomen  para- 
lyzed, thus  interfering  with  expira- 
tory movements  of  respiration. 
Electro-muscular  contractility  dim- 
inished or  lost. 

Paralysis  of  legs,  etc.,  as  above. 
Paralysis  of  all  the  intercostal  mus- 


SEAT  OF  LESION. 

In  the  terminatiou  of  the  cord, 
low  down  in  the  sacral  canal. 

In  the  cord  at  the  upper  limit  of 
the  sacral  region. 


In  the  cord,  at  the  upper  limit  of 
the  lumbar  region. 


In  the  cord,  low  down  in  the  cer- 
vical region. 


94 


DIFFERENTIAL    1>IA<  i  N'<  >SIS. 


TABULAE  YIIAV  OF  SPINAL  PARALYSIS. 


SYMPTOMS. 

cles,  and  consequent  interference 
with  inspiration.  Paralysis  of 
muscles  of  upper  extremities,  except 
those  of  the  shoulders,  which  re- 
ceive their  nerves  from  the  higher 
portions  of  the  cervical  region. 

In  addition  to  the  preceding,  dif- 
ficulty of  swallowing  and  vocaliza- 
tion, contraction  of  pupils,  palpita- 
tion of  heart  and  priapism. 

In  addition  to  above,  paralysis  of 
the  phrenic  nerve  and  diaphragm, 
of  the  scaleni,  intercostals,  serrati 
magni,  and  many  of  the  accessory 
respiratory  muscles  which  act  upon 
and  from  the  shoulder.  Death  re- 
sulting at  once  from  suspension  of 
all  respiratory  movements. 

Paraplegia  developing  itself  sym- 
metrically. 

Paraplegia  of  the  legs. 

Paraplegia  of  the  arms. 

Cerebral  paraplegia,  so-called,  are 
very  rare,  and  are  in  reality  two 
distinct  hemiplegia?. 

Paraplegia  from  disease  of  the 
vertebral  column. 


Characteristic  symptoms  of  tabes 
dorsal  is  or  locomotor  ataxia. 

Progressive  muscular  atrophy. 


Hemiplegia  with   crossed   hemi- 
amesthesia. 


SEAT   OF   EESION. 


In  the  cord  below   the    middle 
cervical  region. 


In  the  cord,  at  or  above  the  mid- 
dle of  the  cervical  region,  or  the 
level  of  the  fourth  cervical  pair  of 
spinal  nerves. 


Anterior  half  of  the  medulla 
spinalis  or  its  sheaths. 

Dorso-lumbar  enlargement  of 
cord. 

Cervical  enlargement  of  cord. 

In  both  sides  of  the  brain.  Ex- 
ceptions in  cases  of  disease  of  the 
medulla  oblongata  (very  rare). 

Roots  of  spinal  nerves  at  point  of 
injury,  especially  posterior  roots, 
which  long  remain  in  a  state  of 
painful  excitation. 

Posterior  half  of  med.  spinalis. 

Gray  substance  of  spinal  cord  in 
vicinity  of  the  central  canal  or  dif- 
fused through  anterior  roots. 

In  one  lateral  half  of  spinal  cord. 
The  hyperesthesia  of  the  paralyzed 


DISEASES    OF    THE    NERVOUS   SYSTEM. 


95 


TABULAR  VIEW  OF  SPINAL  PARALYSIS. 


SYMPTOMS. 


Bilateral  neuralgia  of  the  legs  and 
arras  accompanying  symptoms  of 
tabes  dorsalis. 

Bilateral  contractions  affecting  the 
extensor  muscles. 

Unilateral  contractions  affecting 
the  flexor  muscles. 


SEAT  OF   LESION. 

side  is  probably  due  to  paralysis  of 
the  vaso-motor  nerves  of  that  side. 

In  posterior  roots  of  spinal  nerves 
and  their  prolongation  into  the  gray 
substance  of  the  cord. 

In  the  spinal  cord. 


In  the  brain. 


The  diseases  of  the  spinal  marrow  are  classified  by  Dr.  Wood  accord- 
ing to  the  rapidity  of  their  onset,  as  follows,  the  attack  being  considered 
rapid  when  decided  paralysis  has  developed  within  forty-eight  hours : — 


RAPID    ONSET. 


Congestion. 
Meningeal  apoplexy. 
Spinal  apoplexy. 
Acute  myelitis. 


SLOW   ONSET. 

Sexual  exhaustion. 
White  softening. 
Chronic  myelitis. 
Tumors. 


In  congestion  of  the  cord  the  diagnosis  rests  upon :  Suddenness  of 
onset;  uniform,  bilateral  loss  of  voluntary  motion,  reflex  activity  and 
sensation  ;  absence  of  all  symptoms  of  irritation,  such  as  spasms  or 
violent  pains ;  absence  of  constitutional  disturbance.  It  must  also  be 
remembered  that  the  palsy  affects  first  and  most  severely  the  lower  limbs, 
but  may  rise  to  the  arms,  and,  finally,  to  the  muscles  of  respiration,  and 
thus  prove  fatal ;  that  so  far  as  the  paralysis  extends,  all  the  muscles  are 
involved;  that  motion  is  affected  more  than  sensation;  and  that  very 
rarely,  if  ever,  does  ulceration  or  other  indications  of  trophic  changes 
occur. 

In  meningeal  apoplexy  the  symptoms  are  also  due  to  pressure,  but  the 
effused  blood  not  only  disturbs  the  cord  by  pressing  upon  it,  but  also 
irritates  the  membranes  and  the  nerve-roots,  especially  when  first  thrown 
out.  Consequently,  in  the  first  few  hours  or  days  of  a  meningeal 
hemorrhage,  there  are  violent  spasms  and  pains,  due  either  to  an  incipient 

*  From  Prof.  J.  Aitkeu  Meigs'  Lectures  (not  published). 


96 


DIFFERENTIAL   DIAGNOSIS. 


meningitis,  or  more  probably  to  a  direct  irritation  of  the  nerve-roots. 
The  extent  and  amount  of  the  symptoms  vary,  of  course,  with  the 
position  and  amount  of  the  hemorrhage.  Later  there  are  symptoms 
of  pressure,  varying  in  intensity  with  the  amount  of  the  effusion  ;  and 
absence  of  febrile  symptoms,  unless  decided  meningitis  be  produced  by 
the  clot. 

In  true  spinal  apoplexy  the  symptoms  come  on  with  absolute  abrupt- 
ness. The  cord  is  so  small  a  body  that  a  clot  in  its  substance  interrupts 
at  once  its  function.  The  paralyses  of  motion  and  sensation  are  complete, 
and  reflex  movements  are  greatly  exaggerated.  As  there  is  no  correlation 
of  the  spinal  nerve-roots,  the  spasms  and  pains  of  meningeal  hemorrhage 
are  wanting. 

Acute  primary  myelitis  is  a  very  rare  affection.  The  diagnosis  should 
present  no  difficulty.  The  distinct  febrile  reaction,  which  is  stated  to  be 
always  present,  separates  it  at  once  from  all  other  acute  affections  of  the 
cord  proper,  so  that  it  can  be  confounded  only  with  acute  meningitis. 
Probably,  in  the  majority  of  cases,  it  exists  coincidently  with  this 
disorder ;  but  even  when  it  is  isolated,  the  symptoms  at  first  closely 
simulate  those  of  meningitis. 

COMPARISON  OF  ACUTE  SPINAL  DISEASES. 


Constant  pain  in  the  spine 
at  a  point  corresponding 
with  the  upper  limit  of  in- 
flammation, rendered  more 
acute  by  pressure  on  verte- 
bral spine. 

The  alternate  application 
of  ice  and  hot  sponge  to 
spine  causes  the  same  burn- 
ing sensation  at  seat  of 
lesion,  but  above  the  sensa- 
tion is  normal. 

Sensation  as  of  a  cord  or 
ligature  around  the  body  at 
the  limit  of  paralysis  always 
present  when  dorsal  region 
is  affected  ;  when  higher  up 
spasm  of  the  sphincters  and 
priapism  often  occur. 


MENINGITIS. 

Pain  usually  rheumatic  in 
character,  diffused  along 
the  spine,  not  increased  by 
pressure  ;  but  augmented  by 
flexions  of  trunk. 

Nerves,  coming  out 
through  the  inflamed  part 
of  the  meninges,  the  seat  of 
acute  pain,  much  increased 
by  movements  of  limb. 

Frequent  spasms  of  mus- 
cles of  the  back.  Spasm  of 
sphincter  vesicae  may  occur, 
followed  by  retention  of 
urine  and  paralysis. 

Convulsive  movements  of 
paralyzed  parts. 


CONGESTION. 

Formication  alternating 
with  numbness  in  the  be- 
ginning of  the  attack,  es- 
pecially in  fingers  and  toes. 


Only  slight  pain  in  spine, 
scarcely  increased  by  pres- 
sure. 


Frequently  hyperesthe- 
sia;  sphincters  more  para- 
lyzed than  in  other  forms  of 
paralysis(BR0WN  S^quard). 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


07 


COMPARISON  OF  ACUTE  SPINAL  DISEASES. 


MYELITIS. 

Paraplegia  complete. 


MENINGITIS. 


Anaesthesia  or  pares- 
thesia (except  when  gray 
matter  is  not  involved,  which 
is  rare),  muscular  sensibil- 
ity much  impaired,  early. 

When  disease  is  high  up 
in  dorsal  region  energetic 
reflex  movements  may  be 
produced. 

Marked  tendency  to  bed 
sores;  sloughs  form  early  on 
sacrum  and  nates. 


Paraplegia  varies  in  de- 
gree, sometimes  increasing 
and  subsequently  rapidly 
diminishing. 


Anaesthesia     very    rare 
generally  hyperesthesia. 


Increased  reflex  move- 
ments, which  cause  pain, 
may  be  excited. 

Less  marked  in  uncom- 
plicated cases  of  meningitis. 


CONGESTION. 

Paralysis  generally  not 
limited  to  lower  limbs,  but 
involves  upper  extremitie 
and  respiratory  muscles.  In 
some  cases  power  of  mov- 
ing paralyzed  legs  is  better 
after  resting ;  ordinarily, 
however,  the  paralysis  is 
worse  on  first  rising  in  the 
morning. 

Frequently     morbid    in- 
crease of  sensibility. 


Slight  spasmodic  move- 
ments sometimes  observed 
in  paralyzed  parts. 

Ulceration  occasionally 
happens. 


CHRONIC  SPINAL  DISORDERS. 

In  the  slow  or  chronic  forms  of  spinal  disease,  spinal  tumors  may  be 
considered  first.  There  are  three  classes  of  phenomena  to  be  looked  for 
in  this  disease :  local  symptoms  of  diseased  structures ;  atrocious  pains 
at  a  distance  from  the  seat  of  the  disease,  due  to  the  involvement  of 
nerve-roots  and  nerves,  where  they  pass  through  the  inflamed  tissues  ; 
and  paralytic  symptoms,  the  results  of  pressure,  and  to  some  extent 
of  a  local  myelitis.  In  cases  of  suspected  tumors  of  the  spine  all  these 
symptoms  are  to  be  sought  after.  In  cancer  they  are  often  all  present, 
and  the  distant  pains  are  especially  remarkable  for  their  atrocity. 

The  other  chronic  spinal  diseases  may  be  classified  with  reference  to 
the  characteristic  of  tremors  as  follows : — 


WITHOUT   TREMORS. 

Sexual  exhaustion. 
White  softening. 

Chronic  myelitis.  (  s°ftemng. 
J  I  sclerotic. 

Local  myelitis. 


WITH   TREMORS. 

Paralysis  agitans. 
Multiple  sclerosis. 


The  difference  between  sexual  exhaustion  and  myelitis  is  probably  one 
of  degree  only ;   but  the  former  is  curable ;   the  latter  is  not. 


'.IS 


DIFFERENTIAL    DIAGNOSIS. 


CHRONIC  DEGENERATIVE  DISEASES  OF  THE  CORD. 

In  distinguishing  the  various  forms  of  disseminated  or  muUilocular 
cerebrospinal  affections,  the  following  table,  given  by  Professor  Chai:<  <  1 1 . 
will  render  valuable  assistance.  The  symptoms  of  greatest  importance 
are  set  up  in  italics. 

CEREBROSPINAL   AFFECTIONS. 


LOCOMOTOR 
ATAXIA. 


MULTILOCULAR 
SCLEROSIS. 


f  Epileptiform    Apo-  Epileptiform  Apo- 
plectic  Attacks.        plectic  Attacks. 


DISSEMINATED 
STPHILOSIS. 


GENERAL 
PARALYSIS. 


Vertigo. 
Diplopia, 
mas. 

Amaurosis. 


Strabis- 


Inequality  of  Pupils 
Facial  Anaisthesia. 

Deafness. 
Me'nie're's  Vertigo. 
Embarrassment    of 

Speech. 
Laryngismus. 


Vertigo. 
Diplopia. 

Nystagmus. 

Amblyopia, 

Atrophy. 


White 


Embarrassment  of 
Speech. 

Difficult  Degluti- 
tion. 

Pneumoga  stri  c 
Palsy. 


Epileptiform      At-  Epileptiform   Apo- 
tacks.  plectic  Attacks. 

Paraplegic     Hemi- 
plegic  Epilepsy. 

Vertigo.  Vertigo. 

Diplopia.  (Diplopia. 


Amblyopia,     Optic  Amblyopia. 

Neuritis. 

!  Inequality  of  Pupils 
Headache,      Fixed  Headache. 

Pain. 


Embarrassment   of 
Speech. 


Total  Facial  Palsy. 


Gastric  Crises. 
Nephritic  Crises. 
Vesical  Crises. 
Paresis  of  Bladder. 
Cystitis. 


Gastric   Crises.        I  Non-nervous  Crises 


Paresis  of  Bladder. 


f 

Girdle-pain. 

Lightning  pains. 

/  'sen  do  neural  Pains 

Lightning  Pains. 

.;  1 

Hyperesthesia,  An- 

Plaques. 

Spinal,  Hemiances- 

Tingling. 

agsthesia. 

thesia. 

o 

Incoordina ted 

Incoordination. 

Incoordination. 

5 

Movement. 

>  . 

Contractures   and 

Special  Trembling. 

Special    Trembling 

A 

Trepidations. 

of  Hand. 

Spasmodic   Para- 

SpasmodicParaple- 

Paresis.      Trepida- 

pu 

plegia. 

gia  under  form  of 

tion. 

to 

1 

Hemiparaplegia. 

r.    CO 

Eschars. 

Eschars. 

Eschars. 

=  g 

Arthropathies. 

Arthropathies. 

c  g 

Fractures. 

.Muscular  Atrophy. 

Muscular  Atrophy. 

Muscular  Atrophy. 

DISEASES   OF   THE    NERVOUS   SYSTEM.  99 

In  applying  these  symptoms  in  practice,  we  should,  of  course,  give  first 
attention  to  those  which  are  most  characteristic.  Thus,  if  we  observe,  in 
a  patient,  ataxy  with  nystagmus,  we  think  at  once  of  multilocular  sclerosis 
and  not  of  locomotor  ataxy  (tabetic  series),  because  nystagmus  is  a  valu- 
able symptom  of  multilocular  sclerosis.  In  the  same  way  spasmodic 
paraplegia  (recognized  by  the  continual  trembling  movements  which  are 
produced  when  a  single  blow  is  struck  upon  the  muscle)  we  find  is  pro- 
duced by  a  localized  lesion  in  the  cord,  more  particularly  involving  the 
lateral  columns. 

In  order  that  these  forms  shall  be  better  understood,  it  may  not  be  out 
of  place  to  review  some  of  the  chief  points  in  the  clinical  history  of  the 
chief  focal  lesions  caused  by  sclerosis  of  the  cord. 

In  sclerosis  of  the  antero-lateral  white  columns  Dr.  Gowers*  states  that 
there  is  loss  of  voluntary  power  below  the  lesion,  descending  degeneration 
in  the  anterior  and  lateral  columns  (direct  and  crossed  pyramidal  tracts, 
especially  the  latter),  and  over-action  of  the  lower  centres.  This  over- 
action  may  be  manifested  only  as  excessive  knee-reflexf  and  developed 
ankle-clonus  (tendon-reflex),  or  it  may  increase  from  this  to  spasm  and 
rigidity — spastic  paraplegia.  There  is  no  wasting  unless  the  degeneration 
extends  from  the  lateral  columns  to  the  anterior  cornua.  Then  we  have 
a  combination  of  spasm  and  wasting,  in  which,  if  the  cornual  degeneration 
proceeds,  the  spasm  and  rigidity  may  lessen  as  the  degeneration  advances. 
In  disease  limited  to  the  lateral  columns  (at  any  rate,  when  the  disease  is 
limited  to  the  pyramidal  tracts)  there  is  no  loss  of  sensation  or  incoordina- 
tion, and  no  interference  of  the  nutrition  of  the  skin.  These  symptoms 
of  "spastic  paraplegia"  [lateral  sclerosis)  may  arise  from  a  primary  de- 
generation in  the  lateral  columns,  limited  thereto.  Such  cases  are 
extremely  rare,  and  in  the  majority  the  disease  is  a  focal  lesion  more  or 
less  extensive  at  some  level  in  the  dorsal  or  cervical  cord,  and  the 
degeneration  in  the  lateral  columns  is  secondary.  The  evidence  of  the 
latter  form  is  afforded  by  the  frequently  sudden  or  rapid  onset  of  the 
symptoms  in  the  first  instance  (primary  sclerosis  being  always  gradual  in 
onset),  and  the  evidence  which  may  generally  be  discovered  that  there 
has  been  at  some  time,  or  is  in  some  region,  damage  which  extends 

*  Address  delivered  before  the  Medical  Society  of  Wolverhampton,  Oct.  7th,  1879. 
f  See  page  102,  note  on  Patellar-Tendon  Reflex. 


100  DIFFERENTIAL   DIAGNOSIS. 

beyond  the  lateral  columns.  Descending  lateral  sclerosis,  with  secondary 
spasmodic  phenomena  in  the  limbs,  may  even  result  from  damage  to  the 
motor  tracts  above  their  decussation — in  the  medulla,  the  puns,  or  the 
motor  parts  of  the  cerebral  hemispheres.  It  occasionally  results  from 
bilateral  injury  to  the  surface  of  the  brain  during  difficult  birth,  but  such 
cases  are  very  rare. 

2.  In  disease  of  the  posterior  columns  there  is  interference  with 
coordination  without  loss  of  power ;  eccentric  pains,  impaired  sensation 
and  diminution  of  reflex  action,  in  consequence  of  the  implication  of  the 
sensory  roots.  All  these  symptoms  depend  on  disease  of  the  root-zone  of 
the  posterior  columns.  Disease  of  the  posterior  median  column  gives 
rise  to  no  known  symptoms. 

The  posterior  columns  may  be  damaged  by  any  pathological  process, 
and  they  are  frequent  seats  of  primary  degeneration.  The  symptoms 
of  locomotor  ataxy  usually  present  the  following  order :  loss  of  the  deep 
reflexes,  pains,  incoordination,  diminution  of  sensation ;  loss  of  the 
superficial  reflexes,  occasionally  interference  with  the  nutrition  of  bones 
and  joints. 

There  is  no  loss  of  motor  power  or  wasting  as  long  as  the  disease 
remains  limited  to  the  posterior  columns.  It  may,  however,  extend 
forward  into  the  anterior  cornua,  causing  muscular  atrophy  and  weakness 
to  be  conjoined  with  the  ataxy.  Or  the  lateral  columns  may  be  affected 
at  the  same  time  as  the  posterior ;  we  then  have  weakness  as  well  as 
ataxy,  but  no  wasting.  The  disease  of  the  lateral  columns  causes  increase 
of  the  deep  reflexes,  and  this  increase  may  thus  coexist  with  incoordina- 
tion, the  increased  action  of  the  reflex  centres  being  so  great  that  they  are 
not  arrested  by  the  damage  to  the  posterior  root  (which  is  often,  in  these 
cases,  slight).  Thus  we  have  the  anomaly  of  ataxy  with  excess  of  the 
tendon  reflex  instead  of  its  loss. 

An  important  fact  to  remember  regarding  the  posterior  columns  is  their 
proneness  to  degenerate  ;  they  recover  less  readily  than  any  other  part  ot 
the  cord.  A  lesion  in  one  spot  may  set  up  a  degeneration  which 
ultimately  involves  them  in  their  whole  extent.  Damage  affecting  the 
whole  thickness  of  the  cord  may  pass  away  from  the  rest  and  persist  in  the 
posterior  columns,  and  even  spread  there.  In  such  a  case  we  have  ataxy 
succeeding  loss  of  power.     Strength  returns,  incoordination  remains. 


DISEASES    OF   THE    NERVOUS  SYSTEM.  101 

3.  The  anterior  cornua  contain  the  motor  nerve-cells,  which,  (1) 
influence  the  nutrition  of  the  motor  nerve  fibres  proceeding  from  them, 
and  consequently  that  of  the  muscles;  (2)  constitute  the  terminal  link  in 
the  path  of  the  voluntary  impulse  from  the  brain  to  the  muscles ;  (3) 
form  part  of  the  reflex  loop,  probably  also  of  the  reflex  centre,  to  which 
those  muscles  are  connected. 

Hence  we  have  as    the   result   of   disease   of   the  anterior   cornua, 

(1)  degeneration    of  the   motor    nerves    and  wasting   of  the  muscles ; 

(2)  loss  of  voluntary  power,  i.  e.,  paralysis  of  those  muscles  ;  (3) 
interference  with  or  arrest  of  the  reflex  actions  in  which  these  muscles 
take  part. 

The  extent  of  these  symptoms,  whether  they  are  unilateral  or  bilateral, 
affect  many  muscles  or  few,  will  depend  strictly  on  the  extent  of  the 
disease  in  the  spinal  cord. 

Of  the  three  symptoms  the  muscular  wasting  is  incomparably  the  most 
important.  Paralysis  may  result  from  disease  elsewhere  in  the  motor 
tract,  i.e.,  disease  of  the  lateral  column  higher  up.  Loss  of  reflex  action 
may  depend  on  disease  elsewhere  in  the  reflex  loop,  i.  e.,  disease  of  the 
sensory  fibres  in  or  outside  the  cord.  But  muscular  wasting  is  due  only 
to  a  lesion  of  the  motor  cells,  or  to  a  lesion  of  the  nerves  cutting  the 
muscles  off  from  the  influence  of  these  cells.  In  most  cases  we  are  able 
to  exclude  the  latter  without  difficulty  ;  the  state  of  muscular  nutrition 
comes  thus  to  be  of  the  highest  importance  as  indicative  of  the  state  of  the 
anterior  cornua  of  the  cord. 

Disease  of  the  anterior  cornua  is  often  combined  wTith  disease  of  the 
lateral  (pyramidal)  columns  similar  to  the  descending  degeneration. 
Charcot  believes  that  in  these  cases  the  degeneration  in  the  lateral 
column  is  primary,  its  symptom,  muscular  rigidity,  preceding  the 
symptom  of  the  cornual  disease,  muscular  wasting,  and  he  terms  the 
affection  "lateral  amyotrophic  sclerosis."  I  believe,  however,  that  this 
position  will  need  reconsideration,  and  that  the  degeneration  in  the  lateral 
columns  is,  sometimes  at  least,  secondary  to,  or  simultaneous  with,  the 
disease  in  the  cornua.  It  often  spreads,  however,  beyond  the  fibres  related 
to  the  degenerated  cornua,  and  so  may  cause  weakness  and  spasm  in  the 
limbs  below  the  seat  of  the  muscular  atrophy.  Thus  we  have  wasting 
in  the  arms,  and  weakness  with  spasm  in  the  legs,  and  even,  as  I  have 


102  DIFFERENTIAL   DIAGNOSIS. 

seen,  wasting  in  the  should er-muscles,  and  weakness  without  wasting  in 
the  hands. 

( Vrtain  lesions  may  damage  the  motor  tracts  slightly  and  impair  con- 
duction in  a  peculiar  way,  rendering  it  apparently  unequal  in  different 
fibres.  As  a  consequence  the  muscular  action  is  unequal  in  different 
muscles,  and  instead  of  a  balanced  coordinated  movement  we  have  an 
unbalanced  jerky  movement.  This  is  seen  especially  when  irregular 
islets  of  sclerosis  affect  the  cord — disseminated  or  insular  sclerosis — and, 
according  to  the  researches  of  Charcot,  it  appears  that  this  irregular 
conduction  is  the  result  of  the  unequal  wasting  of  the  medullary  sheaths, 
the  axis-cylinders  remaining.  A  precisely  similar  symptom  may  result 
from  pressure  on  the  motor  tract — as  by  a  growth.  Not  rarely  this 
"disseminated"  or  "insular"  sclerosis  in  one  region  is  combined  with  a 
system-degeneration  in  another.  An  occasional  combination,  for  in- 
stance, is  the  jerking  movement  (from  cervical  insular  sclerosis)  in 
the  arms,  and  weakness  with  spasm  (from  lumbar  lateral  sclerosis)  in  the 
legs. 

4.  A  total  transverse  lesion  of  the  cord  at  any  level,  however  limited 
in  vertical  extent,  separates  all  parts  below  the  lesion  from  the  brain,  and 
hence,  so  far  as  will  and  perception  are  concerned,  produces  the  same 
effect  as  if  the  whole  of  the  cord  below  the  lesion  were  destroyed.  A 
section  across  the  cord  in  the  middle  of  the  cervical  enlargement,  for 
instance,  paralyzes  all  parts  below  the  neck.  Hence  the  extent  of  the 
paralysis  indicates  only  the  upward  extent  of  the  lesion.  This  is  also 
indicated  by  the  position  of  the  girdle  pain,  or  zone  of  hyperesthesia, 
which  is  due  to  the  irritation  of  the  sensory  roots  in  the  lowest  part  of 
the  upper  segment — an  important  indication  when  the  lesion  is  in  the 
dorsal  region,  where  the  precise  limitation  of  motor  weakness  may  be 
recognized  with  difficulty. 

Patellar- Tendon  Reflex. — For  the  diagnosis  of  posterior  sclerosis,  West- 
phal  has  noted  the  following  symptom:  "  If  a  healthy  man  sits  with  one 
knee-joint  resting  upon  the  other  (a  very  common  attitude),  and  the  liga- 
mentum  patella?  of  the  supported  leg  be  smartly  struck  just  below  the  knee- 
cap with  the  side  of  the  hand,  a  sudden  contraction  takes  place  in  the  qua- 
driceps femoris  muscle  (of  which  the  ligamentum  patella?  represents  the 
tendon),  and  the  foot  is  consequently  jerked  upward  to  a  degree  which 


DISEASES    OF   THE    NERVOUS  SYSTEM.  103 

varies  in  different  individuals.  Now,  in  eonfirmed  examples  of  locomotor 
ataxia  this  reaction  does  not  take  place.  No  matter  on  what  part  of  the 
ligament  below  the  knee-cap,  or  with  what  force  the  blow  is  struck,  the 
foot  hangs  motionless.  In  order  to  establish  with  accuracy  the  absence 
of  the  phenomenon,  certain  precautions  ought  to  be  taken.  The  leg 
should  be  bare;  the  patient  must  not  offer  voluntary  resistance  to  the 
movement  of  his  leg,  and  the  ligament  should  be  struck  with  some  hard 
implement  which  can  be  swung  like  a  hammer.  An  ordinary  wooden 
stethoscope  answers  very  well  if  it  is  held  loosely  by  the  small  end,  and 
the  blow  given  with  the  edge  of  the  ear-piece.  But,  however  adminis- 
tered, several  blows  should  be  struck  on  the  ligament,  slightly  changing 
the  position  each  time,  as  there  is  generally  one  spot  from  which  the 
reaction  is  peculiarly  energetic.  This  is  usually  a  little  below  but  very 
near  to  the  patella.  Ankle-clonus  may  be  similarly  developed  by  tapping 
the  tendo-Achillis. 

The  following  are  the  conclusions  given  by  Erb*  in  regard  to  the 
interpretation  of  symptoms  : — 

In  diseases  of  the  spinal  cord,  paralysis  rapidly  followed  by  a  marked 
degree  of  atrophy  and  by  the  reaction  characteristic  of  degeneration, 
points  to  disease  of  the  anterior  roots  (rarely),  or  of  the  gray  anterior 
cornua  (more  frequently).     In  this  case  all  reflex  actions  are  absent. 

Paralysis  with  tension  and  contraction  of  muscles,  without  atrophy,  is 
very  probably  due  to  some  affection  of  the  lateral  columns. 

Paralysis  without  loss  of  reflex  function  and  without  atrophy,  points  to 
an  affection  of  the  parts  which  ascend  to  the  brain,  outside  of  the  gray 
substance,  or,  at  least,  outside  of  the  ganglia  of  the  anterior  cornua. 
Such  are  mostly  cases  of  circumscribed  disturbances  of  conduction,  the 
end  of  the  cord  below  the  lesion  remaining  intact. 

Paralysis,  with  trophic  disturbances,  gives  room  for  suspecting  an  affec- 
tion of  the  gray  substance,  since  primary  affections  of  the  roots  are  rare. 

Very  extensive  palsy,  with  much  atrophy,  the  reaction  of  degeneration, 
absence  of  reflex  acts,  points  to  a  widely  diffused  lesion  of  the  anterior 
gray  substance. 

Paralysis  in  the  districts  supplied  by  certain  pairs  of  roots  (both  arms 
alone,  or  both  crural  nerves)  points  to  a  strictly  localized  affection  of  roots,  or 

*Erb. — Review  in  Journal  of  Nervous  and  Mental  Diseases,  Chicago,  Oct.,  1878. 


104 


DIFFERENTIAL   DIAGNOSIS. 


lesion  of  the  gray  anterior  eornna.  The  conclusions  in  regard  to  the  nature 
of  the  lesion  in  the  cord  are  far  less  certain  than  those  relating  to  its  place. 

Cases  of  spinal  paralysis,  accompanied  by  atrophy  of  the  muscles, 
whether  in  children  or  adults,  acute  or  chronic,  are  described  under  the 
head  of  poliomy el it  is  anterior,  acuta  and  chronica. 

Destruction  of  the  central  trophic  apparatus,  or  its  separation  from  the 
peripheral  parts,  produces  the  symptoms  of  degenerative  atrophy.  "  Upon 
the  whole,  we  arc  justified  in  assuming  a  disease  of  the  anterior  cornua 
when  the  electrical  examination  shows  the  existence  of  the  reaction  of 
degeneration,  and  consequently  of  degenerative  atrophy  of  nerves  and 
muscles,  provided  the  disease  is  clearly  of  spinal  origin"  (Erb). 

In  infantile  palsy  (lesion  in  the  anterior  cornua),  observers  are  not 
agreed  as  to  whether  the  change  in  the  ganglion  cell  is  primary  or  whether 
it  is  the  consequence  of  an  interstitial  myelitis. 

The  following  table  will  be  found  valuable  in  diagnosticating  certain 
chronic  disorders  (chiefly  after  Prof.  Meigs). 

PARALYSIS  AGITANS. 


CEREBRO-SPINAL 
SCLEROSIS. 

Disease  of  adult  life. 

Tingling  and  numbness  ; 
diminished  muscular  power, 
chiefly  in  the  legs. 

Eye  symptoms  absent  in 
spinal  form  ;  when  they  oc- 
cur in  cerebro-spinal  form 
they  are  persistent  and  pro- 
gressive. 

Tremor  or  trembling  fol- 
lows the  paralysis. 

One  or  both  limbs  paretic, 
ultimately  becoming  com- 
pletely powerless. 


In  the  paretic  stage  the 
gait  is  distinctive  ;  the  foot 
is  swung  around,  describing 
an  arc  of  a  circle,  and 
brought  flatly  upon  the 
ground.  With  this  eccen- 
tric curvilinear  projection 
of  the  foot  there  is  an  exag- 
gerated alternate  semi-ro- 
tation of  both  halves  of  the 
pelvis. 


In  old  persons  chiefly. 
Felt  mainly  in  the  arms. 


No  proper  eye  symptoms. 


Precedes  paralysis. 

Muscular  weakness  in  one 
or  both  arms,  and  then  ex- 
tends into  lower  extremities. 
Only  rarely  passing  into 
true  paralysis. 

In  attempting  to  walk 
first  balances  on  his  feet, 
and  starts  with  head  and 
trunk  bent  forward  on  the 
toes  or  fore  part  of  feet, and 
with  short  steps  goes  hop- 
ping and  trotting  along  at 
almost  running  speed  (fus- 
tination). 


LOCOMOTOR  ATAXIA. 

In  adults. 

Tingling  and  numbness 
of  legs  without  loss  of  pow- 
er (want  of  coordination 
exists). 

Ocular  troubles,  defect- 
ive vision  and  accommoda- 
tion, strabismus,  ptsosis  or 
double  vision.  These  symp- 
toms temporary. 

Absent. 

No  paralysis. 


A   stumbling,  staggering 
gait,  without  true  paralysis. 


DISEASES    OF   THE   NERVOUS   SYSTEM. 


105 


CEREBROSPINAL 
SCLEROSIS. 

No  spontaneous  tremor ; 
always  caused  by  motion  or 
excitement. 

Nystagmus,  usually  bin- 
ocular. 

Articulation  slow  and 
scanning. 

Intellect  early  impaired. 

Boring,  gnawing  and  lan- 
cinating pains  rarely  com- 
plained of. 

Earlyparesis, passing  into 
paralysis,  is  characteristic. 


PARALYSIS  AGITANS. 

Trembling  early,  inces- 
sant, even  when  at  rest  ; 
scarcely  interrupted  by 
sleep. 

Never  met  with. 

Articulation  indistinct  ; 
embarrassed. 

Unaffected  until  late. 


LOCOMOTOR  ATAXIA. 

No  tremor. 

Not  present. 

Not  affected. 

Not  marked. 

Such     pains     frequently 
precede  the  loss  of  motion. 

Paraplegia  always  a  late 
phenomenon. 

(For  diagnosis  of  Locomotor  Ataxia  from  General  Paralysis  of  the 
Insane,  see  page  111,  under  this  head.) 

Paralysis  may  also  be  caused  by  reflex  irritation,  and  closely  simulate 
organic  disease  of  the  cord.  Brown-Sequard  *  gives  the  following 
points  of  distinction  (with  unimportant  additions) : — 

PARAPLEGIA. 


FROM  REFLEX  IRRITATION. 

1.  Is  preceded  by  an  affection  of 
uterus,  bladder,  kidneys,  or  pros- 
tate gland.  May  be  caused  by 
phimosis. 

2.,  Usually  lower  limbs  alone  par- 
alyzed. 

3.  No  gradual  extension  of  the 
paralysis  upward. 

4.  The  paralysis  is  usually  incom- 
plete, an  extreme  debility  or  weak- 
ness of  the  limbs  rather  than  par- 
alysis. 

5.  Some  muscles  more  paralyzed 
than  others. 


6.    Reflex   power  neither    much 
increased  nor  completely  lost. 

*  "  Lectures  on  the  Diagnosis  and  Treatment  of  Paraplegia,"  p.  33 


FROM  MYELITIS. 

1.  Usually  no  disease  of  the 
genito-urinary  organs  except  as  con- 
sequent on  the  paralysis. 

2.  Usually  other  parts  paralyzed 
besides  the  lower  limbs. 

3.  Most  frequently  a  gradual  ex- 
tension of  the  paralysis  upward. 

4.  Very  frequently  the  paralysis 
is  complete. 


5.  The  degree  of  paralysis  the 
same  in  the  various  muscles  of  the 
lower  limbs. 


6.  Reflex  power  often   lost;    or 
sometimes  much  increased. 


106 


DIFFERENTIAL   DIAGNOSIS. 


PARAPLEGIA  {Continued). 


FROM  REFLEX  IRRITATION. 

7.  Bladder  and  rectum  rarely 
paralyzed ;  or  at  least  only  slightly 
so ;  sphincter  ani  weak. 

8.  Spasms  in  paralyzed  muscles 
extremely  rare. 

9.  Very  rarely  pains  in  the  spine, 
either  spontaneously  or  on  applica- 
tion of  pressure,  percussion,  or  a 
hot,  moist  sponge,  or  ice. 

10.  No  feeling  of  pain  or  con- 
striction around  the  abdomen  or 
chest. 

11.  No  formication,  pricking,  or 
disagreeable  sensations  of  cold  or 
heat. 

12.  Anaesthesia  rare,  the  tactile 
sensibility  being  but  slightly,  if  at 
all,  impaired;  but  the  muscular  sense 
is  almost  lost. 

13.  Usually  obstinate  gastric  de- 
rangement. 

14.  Variations  in  the  degree  of 
the  paralysis  corresponding  with 
changes  in  the  primary  disease. 

15.  Usually  the  urine  is  acid,  un- 
less the  urinary  organs  are  diseased. 

16.  Cure  of  the  paralysis  fre- 
quently and  rapidly  obtained,  or 
taking  place  spontaneously  after  a 
notable  amelioration  or  cure  of  the 
genito-urinary  affection. 

17.  Usually  muscles  do  not  be- 
come atrophied,  and  temperature  is 
little  lowered. 

18.  Therapeutic  results  good. 


FROM  MYELITIS. 

7.  Bladder  and  rectum  usually 
completely  paralyzed,  or  nearly  so. 

8.  Always  spasms,  or,  at  least, 
twitchings. 

9.  Always  some  degree  of  pain 
existing  spontaneously,  or  caused  by 
external  excitations. 


10.  Usually  a  feeling  as  if  a  cord 
were  tied  tightly  around  the  body 
at  the  upper  limit  of  the  paralysis. 

11.  Always  formications,  or  prick- 
ing, or  both,  and  very  often  sensa- 
tions of  pricking  or  heat  or  cold. 

12.  Anaesthesia  very  frequent  and 
always  at  least  numbness. 


13.  Gastric  digestion  good,  unless 
the  myelitis  has  extended  high  up 
in  cord. 

14.  Ameliorations  very  rare,#and 
not  following  changes  in  the  condi- 
tion of  the  urinary  organs. 

1 5.  Urine  almost  always  alkaline. 

16.  Frequently  a  slow  and  grad- 
ual progress  towards  a  fatal  issue, 
and  rarely  a  complete  cure. 


17.  Atrophy  of  muscles  of  the 
paralyzed  parts. 

18.  Treatment  of  little  benefit. 


DISEASES    OF  THE   NERVOUS   SYSTEM.  107 

Mr.  Gowers  divides  spinal  lesions,  according  to  the  time  required  in 
their  development,  into  six  classes,  whose  comparative  features  are  shown- 
in  the  following  table  : — 

Sudden  [few  minutes).  \  Vascular  lesions. 

Acute  {few  hours  or  days).  j*  ^1 

Pressure     f  Sub-acute  (one  to  four  weeks)  I  lnflammation  (myelitis). 

J  Sub-chrome  (one  to  two  months).  J 

r,        ,1       }  Chronic  (two  to  six  months).  J    )  -r^  ,• 

Growths.    Kr        i       •  /  •  4.u       i  a\   r  Degeneration. 

^  V  ery  chronic  (six  months  and  upward).  J       & 

» 

He  recommends,  in  examining  a  case  of  disease  of  the  spinal  cord,  to 

follow  a  definite  plan.    "  First  endeavor  to  ascertain  the  exact  seat  of  the 

lesion ;  note  how  far  the  several  conducting  functions  of  the  cord  are 

impaired ;  and  the  highest  level  of  their  impairment ;  then  ascertain  the 

condition  of  the  central  functions,  and  especially  muscular  nutrition,  and 

irritability  and  reflex  action  (first  in  the  part  below  the  level  at  which 

conduction  is  impaired ;   and   secondly,   at  the  supposed   level   of  the 

lesion,  and  in  this  way  you  may  infer,  without  much  difficulty,  what  is 

the  extent  of  the  lesion  transversely  and  vertically).     In  the  next  place, 

endeavor  to  ascertain  its  nature  by  considering,  first,  how  the  symptoms 

came  on  and  developed ;  secondly,  which  of  the  lesions  having  this  mode 

of   onset   and    development  are  common  in  the  region  affected ;    and 

thirdly,  which  of  them  are  produced  by  the  cause  or  causes  to  which  the 

disease  is  apparently  due." 

Some  special  forms  of  paralysis  require  separate  discussion. 

PSEUDOHYPERTROPHIC  PARALYSIS. 

This  is  a  disease  of  children,  usually  attacking  them  in  the  second 
year  of  life.  At  that  period  it  is  found  that  when  they  are  placed  upon 
their  feet  they  fall  down,  or  clutch  at  the  nearest  object,  to  support  them- 
selves; or  in  other  cases  it  may  be  that  the  child  has  commenced  to  walk, 
when,  without  pain  or  fever,  or  sometimes  after  convulsions,  it  is  found 
to  be  soon  fatigued,  either  by  walking  or  standing,  and  at  length  it  can 
no  longer  walk  or  hold  itself  upright;  or,  again,  it  may  be  that  the 
child  does  not  walk  until  very  late,  2 J  or  3  years,  and  then  very  feebly 
and  imperfectly. 

Symptoms. — The  principal  morbid  phenomena  are  (Duchexxe) — 


108  DIFFERENTIAL   DIAGNOSIS. 

1st.  In  the  beginning,  feebleness  of  the  lower  limbs. 

2J.  Lateral  balancings  of  the  trunk  and  widening  of  the  legs  during 
walking. 

3d.  A  peculiar  curvature  of  the  spine  (ensellure),  or  saddle-back 
(lordosis),  both  in  walking  and  standing. 

4th.  Equinism  (talipes  equinus),  with  a  peculiar  over-extension  of  the 
first  phalanges  of  the  toes,  which  Duchenne  calls  "griffe  des  orteils." 

5th.  Apparent  muscular  hypertrophy. 

6th.  Stationary  condition. 

7th.  Generalization  and  aggravation  of  the  paralysis. 

"When  the  disease  has  arrived  at  the  stage  of  apparent  hypertrophy, 
the  appearance  of  the  patient  is  very  characteristic,  and  its  true  nature 
would  be  at  once  obvious  to  any  one  who  had  any  knowledge  of  its 
symptoms ;  but  in  the  earlier  stages  there  is  but  little  to  guide  us  to  a 
diagnosis  unless  we  have  some  hereditary  history.  Of  the  hereditary 
nature  of  this  affection  the  published  cases  give  ample  proof. 

There  are  apparently  two  forms  of  this  disease,  one  of  spinal  the 
other  of  muscular  origin. 

PARALYSIS,  FROM  LEAD  POISONING  AND  HYSTERIA. 

In  this  form  of  paralysis  the  usual  diagnostic  symptoms,  to  wit,  a 
history  of  exposure  to  lead,  the  blue  line  on  the  gums,  constipation  and 
colic,  may  all  be  absent ;  hence  the  diagnosis  must  rest  upon  the  peculiar 
characters  of  the  palsy — especially  the  effects  of  electric  currents  upon 
the  muscles.  These  are  the  only  reliable  evidences  of  the  nature  of  the 
disease.  These  characteristic  reactions,  first  described  by  Duchenne, 
are  as  follows  : — 

Excitability  to  Faradaism  absent  or  sensibly  diminished  in  all  the 
muscles  of  the  forearm  except  the  supinators  longus  and  brevis.  In 
health  the  supinator  brevis  cannot  be  directly  Faradized,  on  account  of  its 
deep  position.  But  in  lead  palsy  it  very  often  happens  that  the  wasting 
of  the  extensor  communis  digitorum  has  proceeded  far  enough  to  uncover 
the  supinator  brevis  sufficiently  to  allow  a  small  rheophore  to  be  applied 
to  it  in  the  space  of  about  a  square  inch  at  the  upper  and  back  part  of 
the  forearm.  If  it  be  found  (both  arms  being  affected)  that  the  common 
extensor  fails  to  respond  to  Faradaism  while  the  short  supinator  close  by, 


DISEASES    OF  THE  NERVOUS   SYSTEM.  109 

on  a  lower  plane,  is  readily  excited  by  it,  the  case  may  be  positively  set 
down  as  one  of  lead  palsy. 

Hysterical  Paralysis,  in  spite  of  its  frequent  close  imitation  of  the 
organic  forms,  is  readily  diagnosed  by  attention  to  the  following 
points : — 

1.  In  hysterical  hemiparesis  the  face  is  rarely,  and  the  tongue  never, 
affected. 

2.  In  hysterical  paraplegia  incontinence  of  urine  is  never  present 
(Hamilton). 

3.  No  amount  of  help  can  keep  the  patient  from  staggering  or  falling 
when  she  attempts  to  walk  (Reynolds). 

4.  The  foot  in  walking  is  simply  dragged  along  and  not  swung  as  in 
organic  hemiplegia  (Todd). 

5.  In  all  sudden  cerebral  palsies,  the  nails  of  the  affected  extremities 
cease  to  grow.  In  hysterical  palsies,  of  one  limb  or  both,  whether  para- 
plegic or  hemiplegic,  the  rate  of  nail-growth  is  unaltered  (Weir 
Mitchell). 

GENERAL  PARALYSIS  OF  THE  INSANE. 

This  curious  disease,  long  unknown  in  the  United  States,  has  of  recent 
years  been  frequently  observed  in  the  Northern  and  Eastern  States,  but 
so  far,  rarely  or  not  at  all  in  the  South  and  West.  It  is  a  disease  of  ad- 
vanced life,  whose  pathognomonic  characteristics  are  constant  troubles  of 
motility,  a  progressive  loss  of  mental  power,  and  a  constant  belief  on  the 
part  of  the  patient  that  he  is  perfectly  well,  and  in  the  enjoyment  of 
magnificent  fortune  and  gigantic  powers  (delires  des  grandeurs). 

The  following  are  the  progressive  traits  of  the  disease  as  generally  ob- 
served : — 

Psychical  Symptoms. — 1.  General  restlessness  and  unsteadiness  of 
mind,  with  impairment  of  attention ;  alternating  with  apathy  and  drowsi- 
ness. 

2.  A  change  in  disposition  and  temper,  and  a  general  loss  of  self- 
restraint;  at  first  as  regards  trivial  social  observances,  and  then  as  re- 
gards general  conduct. 

3.  Impairment  of  the  reflective  powers,  so  that  there  is  no  logical  and 
systematic  development  of  thought. 


110  DIFFERENTIAL   DIAGNOSIS. 

4.  General  exaltation  of  thought,  with  a  profusion  of  remembered 
images  and  ideas,  and  numerous  extravagant  desires. 

5.  Failure  of  memory  and  forgetfulness;  at  first  of  words,  and  then  of 
events. 

6.  Delirious  conceptions,  and  the  transformation  of  desires  into  beliefs, 
these  being  generally  connected  with  personal  greatness  and  power. 

7.  Hallucinations  of  the  senses,  in  which  remembered  sense  impres- 
sions are  so  vivid  and  intense  as  to  spread  to  the  periphery. 

8.  Maniacal  restlessness  and  excitement,  in  which  present  impulses  and 
feelings  instantly  pass  over  into  action. 

9.  Increased  mental  weakness,  with  the  incoherent  and  fragmentary 
repetition  of  the  false  ideas  previously  entertained. 

10.  Failure  of  the  senses,  with  more  marked  impairment  of  memory. 

11.  Complete  fatuity,  passage  into  coma  and  death. 

Motor  Symptoms. — 1.  Persistent  contraction  of  the  occipito-frontalis 
muscle,  and  some  dilatation  of  pupils,  causing  the  eyes  to  be  widely 
opened  and  the  forehead  wrinkled,  and  giving  an  expression  of  sur- 
prised attention  to  the  face. 

2.  Persistent  contraction  and  frequent  tremors  of  the  zygomatic 
muscles,  giving  a  pleased  and  benevolent  expression  of  countenance. 

3.  Slight  muscular  restlessness  and  unsteadiness. 

4.  Impairment  of  the  power  of  executing  fine  and  detailed  movements, 
so  that  manipulative  skill  is  lost  while  movements  en  masse  are  still  well 
performed. 

5.  Fibrillar  tremors  of  the  tongue,  and  some  loss  of  control  over  its 
movements,  so  that  it  is  protruded  with  difficulty ;  is  rolled  about  when 
protruded,  and  is  suddenly  withdrawn. 

6.  Twitchings  of  the  nostrils  and  upper  lip,  with  frequent  tremors  of 
the  latter. 

7.  Impairment  of  articulation,  which  is  thick  and  wanting  in  distinctness. 

8.  An  alteration  in  the  voice,  as  well  as  thickness  and  hesitancy  in 
speech. 

9.  Loss  of  control  over  the  combined  movements  of  the  hand  and 
wrist,  so  that  the  handwriting  generally  deteriorates. 

10.  Changes  in  the  pupils,  which  are  at  first  irregularly  contracted, 
and  then  become  irregularly  dilated. 


DISEASES   OF  THE   NERVOUS   SYSTEM.  Ill 

11.  An  alteration  in  gait,  which  becomes  unsteady;  the  more  complex 
movements  of  the  thighs,  leg,  and  foot,  and  the  balancing  of  the  pelvis 
on  the  hip  joints,  being  performed  with  difficulty. 

12.  General  muscular  agitation  and  restlessness. 

13.  Gradual  loss  of  power  in  the  muscles  of  the  face,  tongue,  neck,  and 
limbs. 

14.  Spasmodic  contraction  of  the  masseter  muscles,  causing  grinding 
of  the  teeth. 

15.  Convulsive  seizures — most  marked  on  one  side  of  the  body,  and 
followed  by  transitory  hemiplegia. 

16.  Loss  of  control  over  the  sphincters. 

17.  Complete  prostration  of  muscular  strength  and  helplessness,  and 
difficult  deglutition. 

18.  Contractions  of  the  muscles  of  the  limbs,  and  paralysis  of  the 
muscles  of  respiration. 

The  main  diagnostic  difficulty  is  to  distinguish  this  from  some  phases 
of  locomotor  ataxy.  The  differences  are  that  in  general  paralysis  the 
mental  symptoms  are  always  present,  and  always  precede  the  motor 
phenomena.  The  first  symptoms  in  general  paralysis  are  chiefly  cere- 
bral ;  viz.,  mental  excitement,  great  garrulity,  noisy  hilarity,  bragging, 
early  violence  of  behavior,  and  very  usually  some  exhibition  of  libidinous 
conduct;  on  the  subsidence  of  excitement,  the  mind  is  found  to  be  weak, 
and  the  motor  phenomena  gradually  make  their  appearance. 

In  ataxia,  the  commencement  is  in  the  spinal  functions.  There  is  first 
an  attack  of  pain  of  some  remote  part,  occurring  most  frequently  in  the 
lower  extremities,  and  dating  several  years  back,  considered  at  the  time 
perhaps  to  be  rheumatic;  this  pain  is  worse  toward  evening,  or  when  the 
patient  is  not  mentally  occupied ;  it  may  improve  or  disappear  for  a  time 
and  return.  Then  follows  a  slight  degree  of  numbness  of  the  part;  the 
patient  feels  as  if  he  trod  on  wool ;  occasionally  "pins  and  needles"  attack 
the  part;  in  fact,  those  phenomena  which  we  have  all  experienced  after 
sitting  in  an  awkward  position,  when  one's  own  leg  has  "gone  to  sleep." 
There  is,  as  most  of  us  know,  want  of  feeling,  want  of  recognition  of  the 
member,  especially  as  to  its  size,  and  even  its  ownership,  then  atrocious 
pain,  and  pins  and  needles.  In  the  disease,  on  the  subsidence  of  the 
pain,  the  patients  exhibit  some  awkwardness  in  gait;  the  ataxy  or  want 


112 


DIFFERENTIAL   DIAGNOSIS. 


of  order  on  the  movement  is  evident.  These  symptoms  may  extend 
over  teo  or  twelve  years  with  very  little  change,  except,  perhaps,  increas- 
ing awkwardness  in  gait;  there  is  doubtless  some  numbness  of  the  cutane- 
ous surface  in  the  course  of  the  disease;  the  phenomena  appear  to  spread 
upward  by  involving  the  functions  of  the  nerves  higher  up;  the  erection 
of  the  penis,  and  soon  afterward  the  sexual  appetite,  are  lost,  and,  as  the 
disease  ascends,  the  expulsory  power  of  the  bladder  and  rectum  become 
impaired.  All  this  occurs  while  little  change  takes  place  in  the  mental 
functions;  but  in  other  cases  the  mind  appears  imbecile,  the  memory  is 
affected,  and  there  is  distinct  alteration  in  behavior  and  conduct;  but 
there  are  no  lofty  ideas,  no  excessive  excitement  and  garrulity,  and  in  no 
case  paroxysms  of  violence,  or  libidinous  ideas. 

The  differences  may  be  better  seen  in  a  tabulated  form : — 


GENERAL  PARALYSIS. 
Runs  its  course  in  a  few  years. 

Commences  with   mental  symp- 
toms. 

Is  attended  with  libidinous  ideas. 

The  motor  symptoms  are  second- 
ary in  the  order  of  time. 

Is  only  rarely  complicated  with 
pelvic  difficulties. 

There  often  is  great  violence. 


LOCOMOTOR  ATAXY. 

Is  much  slower  usually,  and  may 
last  ten  or  even  twenty  years. 

Commences  with  pains  in  distal 
nerves. 

Is  attended  with  absence  of  sexual 
feeling. 

The  motor  symptoms  are  the  pri- 
mary phenomena. 

Pelvic  symptoms  are  a  prominent 
feature. 

The  mental  phenomena  are  imbe- 
cility and  impaired  memory. 


There  is  also  a  form  of  general  paralysis  due  to  syphilis.  The  differ- 
ential features  of  this  variety  have  been  clearly  defined  by  Dr.  E.  C. 
Seguin.*  We  do  not  obtain  the  regular  gradations  and  stages  of  the 
true  disease.  The  moral  perversion  which  is  peculiar  to  general  paralysis 
is  absent,  neither  do  we  see  the  pure,  exalted  notions.  The  fibrillary 
tremors  that  are  so  well  marked  in  general  paralysis  are  not  present  here. 
The  articulation  is  more  mumbling  in  character.  ~\Vc,  likewise,  are  apt 
to  have  a  great  deal  of  actual  paralysis  of  cranial  nerves  or  body  in  these 
*  Hospital  Gazette,  September,  1878. 


DISEASES    OF  THE    NERVOUS   SYSTEM. 


L13 


cases.  In  true  general  paralysis,  after  attacks  of  hemiplegia,  the  patient 
regains  his  full  strength,  whereas  this  is  not  apt  to  occur  in  the  syphilitic 
variety.  The  following  table  will  perhaps  show  clearly  the  main  differ- 
ences : — 


TRUE  GENERAL 
PARALYSIS. 

Prodromic  stage. 

Exalted  notions,  numerous  and 
varied,  and  relatively  exalted  ac- 
cording to  the  position  in  life. 

Speech  is  tremulous  and  jerky. 

Tremor  of  hands  and  lips. 

Preservation  of  strength. 

Pupils  are  apt  to  be  contracted. 

None. 

None. 

Transient  aphasic  attacks. 

Spontaneous  remissions. 


SYPHILITIC  GENERAL 
PARALYSIS. 

Absent. 

Rare  or  absent. 


Speech  is  thick. 

Absent  as  a  rule. 

Paresis  or  actual  paralysis. 

Apt  to  be  open  or  wide. 

Palsy  of  third  or  of  other  cranial 
nerves. 

Headache  nocturnal. 

More  serious  aphasic  attacks. 

Progressive   except  under  treat- 
ment. 


Some  other  differences  between  the  two  conditions  are  as  follows :  The 
patient  with  syphilis  has  none  of  the  cravings  or  abnormal  appetites  of 
the  other ;  the  latter  feels  an  impulse  to  get  drunk  or  to  have  an  excess 
of  coition.  The  tendency  to  excessive  coition  is  absent  in  syphilitic 
paralysis,  and,  indeed,  there  is  a  marked  loss  of  the  virile  power.  The 
temperature  changes  are  also  absent  in  syphilis  of  the  brain.  The  rise 
in  temperature  in  general  paralysis  of  the  insane  is*very  great,  often 
reaching  103°  in  exacerbations.  There  is  no  rise  of  temperature  in 
syphilis  of  the  brain,  except,  perhaps,  when  the  patient  has  hemiplegia 
from  a  large  lesion. 

The  most  important  point  is,  that  in  syphilis  there  is  a  paralysis ;  in 
general  paralysis  there  is  irritation  and  incoordination  without  true  pa- 
ralysis. 


11-1  DIFFERENTIAL   DIAGNOSIS. 

SPINAL  IRRITATION  (so-called)  AND  SPINAL 
WEAKNESS. 

This  affection  has  been  described  by  some  writers  as  spinal  hyperemia, 
by  others  as  spinal  anannia  ;  again  as  spasms  of  the  spinal  muscles,  and 
lastly  as  abnormality  of  the  spinal  cells.  Some  have  denied  its  exist- 
ence altogether;  but  in  fact  it  is  a  distinctly  defined  and  not  unusual  dis- 
order. About  live-sixths  of  the  cases  are  females,  and  it  is  often  associ- 
ciated  with  uterine  or  ovarian  disease ;  and  as  often  has  some  antecedent 
history  of  a  blow  upon  or  other  slight  injury  to  the  spine. 

Its  symptoms  are  of  the  most  varied  kind,  so  much  so  that  it  may  simu- 
late almost  every  known  ailment;  but  a  careful  examination  of  the  spine 
will  reveal  its  true  character.  The  diagnostic  rules  laid  down  by  Drs. 
William  and  David  Griffin,  in  1834,  who  first  described  the  disease, 
have  never  been  improved  upon.     They  are  as  follows : — 

1.  The  pain  or  disorder  of  any  particular  organ  complained  of  is 
altogether  out  of  proportion  to  the  constitutional  disturbance. 

2.  The  complaints,  whatever  they  may  be,  are  usually  relieved  by  the 
recumbent  position,  are  always  increased  by  lifting  weights,  bending, 
stooping,  or  twisting  the  spine ;  and,  among  the  poorer  classes  are  often 
consequent  to  the  labor  of  carrying  heavy  loads,  drawing  water,  etc. 

3.  The  existence  of  tenderness  at  that  point  of  the  spine  which  corres- 
ponds to  the  disordered  organ,  and  the  increase  of  pain  in  that  organ  by 
pressure  on  the  corresponding  region  of  the  spine. 

4.  The  disposition  to  a  sudden  transference  of  the  diseased  action  from 
one  organ  or  part  to  another,  or  the  occurrence  of  hysterical  symptoms  in 
affections  apparently  acute. 

5.  The  occurrence  of  continued  fits  of  yawning  or  sneezing.  These 
are  not  very  common  in  the  disease;  but  when  they  do  occur,  they  may 
generally  be  considered  as  characteristic  of  nervous  irritation. 

To  this  it  may  be  added  that  the  tenderness  may  extend  along  the 
spine  generally;  but  is  always  greater  in  one  or  two  spots.  Gastric 
symptoms,  headache  and  languor  are  usually  well  marked  in  spinal  irri- 
tation; but  there  is  neither  atrophy,  paralysis  (except  hysterical)  nor  waist 
constriction,  which  serve  to  distinguish  it  from  a  large  class  of  spinal 
diseases. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  1  1  5 

In  regard  to  the  nature  of  spinal  irritation,  we  know  nothing  definite  at 
present  (Erb). 

Neurasthenia  spinalis,  spinal  nervous  weakness,  is  defined  as  a  diseased 
condition  in  which  marked  and  unquestionable  disturbances  of  the  func- 
tions of  the  cord  exist,  for  which  no  considerable  anatomical  basis  can  be 
found  or  assumed ;  a  disease,  therefore,  which  must  at  present  be  classed 
among  the  functional  disorders.  It  is  most  common  among  men,  is 
caused  by  successive  mental  efforts,  sexual  excesses,  bodily  over-exertion. 
Weakness  and  inability  from  prolonged  over-exertion,  dysesthesia,  pares- 
thesia, cold  hands  and  feet,  sleeplessness  and  general  malaise  are  the 
prominent  symptoms. 

"  We  do  not  at  all  know  what  may  be  the  nature  of  the  processes  of 
nutrition  which  cause  these  symptoms.  We,  however,  believe,  that  we  are 
certainly  entitled  to  locate  them  in  the  cord,  especially  in  the  lower 
portion,  the  lumbar  region.  The  most  obvious  view  is  that  which  sup- 
poses that  the  physiological  fatigue  of  the  nervous  elements,  which  always 
occurs  after  severe  and  protracted  irritation,  becomes  exaggerated  and 
assumes  a  fixed  form ;  in  such  a  case  we  may  suppose  that  the  fatigue  of 
the  nervous  elements  does  not  become  repaired  in  the  prompt  manner 
which  is  usual  under  physiological  conditions." 

In  making  a  diagnosis,  these  characters  will  be  distinguished  from 
those  of  disease  of  the  vertebrae  by  eareful  physical  examination,  and  the 
age,  sex  and  history  of  the  case. 

HYSTERIA. 

Few  diseases  present  at  times  greater  difficulties  to  diagnosis  than  this 
protean  complaint.  Its  counterfeits  of  various  maladies  will  be  considered 
elsewhere  (see  the  Index) ;  at  present  we  shall  seek  for  a  pathognomonic 
symptom  of  the  general  condition. 

One  is  offered  by  Dr.  Thomas  Barlow.*  Rejecting  as  unsatisfactory 
all  statements  depending  upon  the  patient's  veracity,  he  finds  a  diagnostic 
test  in  the  presence  of  analgesia.  If,  while  the  patient's  attention  is  directed 
to  something  else,  a  needle  be  introduced  into  the  forearm  and  no  wincing 
occurs,  there  is  the  strongest  presumption  that  we  have  to  do  with  a  case 
of  hysteria.  Again,  it  has  been  long  known  that  hysterical  patients  are 
*  Medical  Times  and  Gazette,  February  1878. 


116  DIFFERENTIAL    DIAGNOSIS. 

often  extremely  tolerant  of  laryngoscopic  examination.  Great  advantage 
will  be  found  in  examining  a  presumed  hysterical  patient's  larynx,  and 
thus  fixing  her  attention  while  somebody  at  the  same  time  inserts  a 
needle  into  her  forearm.  Absolute  tolerance  of  these  two  simple  methods 
of  examination  is  quite  decisive. 

Another  characteristic  relates  to  the  pain  so  frequently  complained  of. 
While  it  is  stated  to  be  exceedingly  acute,  and  the  part  tender  to  the 
slightest  pressure,  if  the  attention  of  the  patient  is  engaged,  very  firm 
pressure  may  be  made  without  the  patient  wincing.  Moreover,  there  is 
noted  very  often  a  co-existence  of  severe  pain  in  the  epigastrium,  the  left 
side  and  spinal  column — the  trepied  hysterique,  or  hysterical  tripod  of 
French  authors. 

The  globus  hystericus,  a  sensation  of  a  foreign  body  in  the  throat  caused 
by  spasmodic  contraction  of  its  muscles,  is  a  common  symptom.  The 
urine  may  be  suppressed,  or  may  be  limpid  and  watery,  and  of  unusual 
quantity. 

If  with  these  traits  are  united  youth  and  female  sex ;  ovarian  or  uterine 
disturbance;  the  general  symptoms  harmonious  and  exaggerated;  the 
mind  clear ;  and  the  disappearance  of  contractions,  etc.,  under  anaesthesia; 
the  diagnosis  is  complete. 

The  most  serious,  mistake  would  be  the  confounding  of  a  hysterical 
paroxysm  with  an  epileptic  fit.  The  following  table  of  distinctions 
between  the  two  is  given  after  Charcot  and  Da  Costa  : — 

EPILEPSY.  HYSTERIA  OR  HYSTERO- 

EPILEPSY. 
Gradual  or  only  partial  or  ap- 
parent unconsciousness. 


Sudden  and  complete  loss  of  con- 
sciousness. 

Livid  face ;  escape  of  frothy  saliva 
from  the  mouth ;  eyelids  half  open ; 
eyeballs  rolling;  grinding  of  the 
teeth ;  biting  of  the  tongue ;  more  or 
less  insensibility  of  the  pupils  to 
light. 

Distortion  of  countenance. 

Patient  evinces  no  feeling. 

Aura  epileptica  of  short  duration. 


Face  flushed  or  complexion  unal- 
tered; no  froth  on  lips;  eyelids 
closed  ;  eyeballs  fixed ;  neither  grind- 
ing of  the  teeth  nor  biting  of  the 
tongue ;  pupils  react  readily. 

No  distortion  of  countenance. 
Patient  sighs,  or  laughs,  or  sobs. 
Aura  often  prolonged  one  or  two 
days.     Globus  hystericus. 


DISEASES    OF  THE    NERVOUS   SYSTEM. 


117 


EPILEPSY. 

Convulsions  often  more  marked 
on  one  side  than  on  the  other ;  and 
more  tonic  than  clonic.  Agitation 
maniacal  and  disorderly. 

Paroxysms  generally  of  short  du- 
ration. 

Paroxysm  followed  by  a  heavy, 
half  comatose  sleep,  by  headache, 
and  dullness  of  intellect.  Stertor. 
No  hallucinations. 


HYSTERIA  OR  HYSTERO- 
EPILEPSY. 
No  such  differences;  convulsions 
clonic.     Agitation  emotional,  often 
en  pose. 

Paroxysms  generally  of  longer 
duration. 

Paroxysm  not  followed  specially 
by  sleep;  patient  often,  after  attack, 
wakeful  and  depressed  in  spirits. 
Little  or  no  stertor.  Hallucina- 
tions. 


Rarely  occurs  at  night. 

Often  connected  with  disorders  of 
the  uterus,  or  of  menstruation. 


Frequently  occurs  at  night. 

No  particular  connection  with 
uterine  disturbance ;  although  a  pa- 
roxysm often  takes  place  at  the 
menstrual  period. 

NEURALGIA. 

The  positive  signs  which  distinguish  a  case  of  pain  to  belong  to  the 
neuralgise  are  succinctly  set  forth  by  Dr.  Francis  E.  Anstie,*  as  fol- 
lows : — 

(1)  The  first  and  most  essential  characteristic  of  a  true  neuralgia  is 
that  the  pain  is  invariably  either  frankly  intermittent,  or  at  least  fluctu- 
ates greatly  in  severity,  without  any  sufficient  and  recognizable  cause  for 
these  changes. 

(2)  The  severity  of  this  pain  is  altogether  out  of  proportion  to  the 
general  constitutional  disturbance. 

(3)  True  neuralgic  pain  is  limited  with  more  or  less  distinctness  to  a 
branch  or  branches  of  particular  nerves ;  in  the  immense  majority  oi 
cases  it  is  unilateral,  but  when  bilateral  it  is  nearly  always  symmetrical 
as  to  the  main  nerve  affected,  though  a  larger  number  of  peripheral 
branches  may  be  more  painful  on  one  side  than  on  the  other. 

(4)  The  pains  are  invariably  aggravated  by  fatigue  or  other  depress- 
ing physical  or  psychical  agencies. 

These  four  cardinal  points  of  the  diagnosis  may  be  further  supported 
*  "  Neuralgia  and  its  Counterfeits,"  p.  565. 


118 


DIFFERENTIAL   DIAGNOSIS. 


by  the  history  bf  the  patient.  Either  (1)  he  has  previously  been  neural- 
gic, or  liable  to  other  neuroses,  or  comes  of  a  neurotic  family  ;  or  (2) 
there  has  been  malarial  poisoning  of  the  blood ;  or  (3)  there  has  been 
some  long  continued  peripheral  or  central  irritation ;  or  (4)  finally,  there 
has  been  constitutional  syphilis. 

The  pains  with  which  neuralgia  is  most  likely  to  be  confounded  are 
those  arising  from  myalgia,  spinal  irritation,  locomotor  ataxia,  cerebral 
abscess,  alcoholism,  syphilis,  chronic  rheumatism,  and  latent  gout. 

In  comparing  the  pains  of  myalgia  and  neuralgia  the  following  are 
the  more  important  points  : — 

MYALGIA. 

Attacks  a  limited  patch  or  patches 
that  can  be  identified  with  the  ten- 
don or  aponeurosis  of  a  muscle 
which,  on  inquiry,  will  be  found  to 
have  been  hard  worked. 


NEURALGIA. 

Follows  the  distribution  of  a  re- 
cognizable nerve  or  nerves. 


Accompanies  an  inherited  or  ac- 
quired nervous  temperament  which 
is  obvious. 

Is  usually  not  much  or  at  all 
aggravated  by  movement. 

Is  at  first  not  accompanied  by 
local  tenderness. 


Painful  points,  when  established 


Often  occurs  in  persons  with  no 
special  neurotic  tendency. 

Is  inevitably  and  very  severely 
aggravated  by  every  movement  of 
the  part. 

Distinguished  from  the  first  by 
localized  tenderness  on  pressure  as 
well  as  on  movement. 

Tender  points  correspond  to  ten- 
in  a  later  stage,  correspond  to  the  dinous  insertions  and  origins  of 
emergence  of  nerves. 

Pain  not  materially   relieved  by 
any  change  of  posture. 


muscles. 

Pain  usually  completely  and  al- 
ways considerably  relieved  by  full 
extension  of  the  painful  muscle  or 
muscles. 


Treatment  also  offers  a  diagnostic  means.  The  pains  of  myalgia  will 
ordinarily  disappear  at  once  by  retaining  the  affected  muscle  at  full  ex- 
te  sion,  surrounding  it  with  moist  warmth,  and  giving  20  or  30  grains 
of  muriate  of  ammonia  internally. 

Spinal  irritation  (spinal  congestion  or  spinal  anaemia)  is  almost  cxclu- 


DISEASES    OF    TIIF    NERVOUS    SYSTEM. 


\V.) 


sively  confined  to  women.  There  are  nearly  always  hysterical  symp- 
toms, marked  superficial  tenderness  over  large  portions  of  the  surface, 
often  merely  cutaneous  and  becoming  less  acute  with  firm  pressure. 
There  are  nearly  always  tender  spots  along  the  spine,  and  also  over  the 
epigastrium  and  the  left  hypoehondrium. 

Locomotor  ataxia  is  mentioned  elsewhere,  and  its  symptoms  described 
in  sufficient  detail.     (See  page  100  et  seq.) 

Cerebral  abscess,  though  rare,  may  give  rise  to  a  regretable  mistake, 
especially  in  its  early  stages,  where  severe  pain  in  the  head  is  almost  the 
only  conspicuous  symptom.  At  this  period  the  diagnosis  from  neuralgia 
must  rest  on  the  following  points  of  contrast : — 


CEREBRAL  ABSCESS. 

Often  occurs  secondarily  to  caries 
of  internal  ear,  and  purulent  dis- 
charges, the  result  of  scarlet  fever, 
measles,  etc.,  in  childhood. 

Frequently  follows  a  blow  or  in- 
jury. 

No  true  "  points  douloureux." 

Usually  the  pain  does  not  com- 
pletely intermit. 

Pain  often  excruciating  from  a 
very  early  period. 

Pain  often  limited  in  situation, 
seems  deep-seated,  though  as  often 
as  not  it  has  no  relation  to  the  site 
of  the  abscess. 

No  well  localized  vaso-motor  or 
secretory  complications. 

Very  rare  in  old  age;  then  usually 
traumatic. 

Relief  from  stimulant  narcotics 
very  transitory. 


NEURALGIA  OF  THE  HEAD. 

Rarely   appears   before   puberty. 
No  local  assignable  cause. 


Comparatively  seldom  caused  by 
a  blow  or  other  external  injury,  or 
caries  of  the  bone. 

If  severe,  soon  presents,  in  most 
cases,  the  "points  douloureux." 

Intermissions  of  pain  complete 
and  of  considerable  length. 

Pain  usually  not  very  violent  at 
first. 

Pain  superficial ;  follows  distribu- 
tion of  recognizable  nerve  branches 
belonging  to  the  trigeminus  or  great 
occipital. 

Usually  lachrymation,  or  conges- 
tion of  the  conjunctiva,  etc. 

Severe  neuralgia  is  commonest  in 
advanced  life. 

Relief  from  opium,  etc.,  is  much 
more  considerable  and  permanent. 


120  DIFFERENTIAL   DIAGNOSIS. 

The  pains  of  chronic  alcoholism  often  closely  simulate  those  of  true 
neuralgia.  The  habits  and  history  of  the  patient,  when  known,  point  to 
the  true  origin  of  the  suffering;  also  the  insomnia,  loss  of  appetite, 
foul  breath,  furred  tongue  and  haggard  countenance  of  the  drunkard  ; 
and  especially  that  the  pains  complained  of  encircle  the  limbs  near  the 
joints,  rather  than  run  longitudinally  the  course  of  the  nerves  in  the 
limb,  are  all  significant. 

The  osteocopic  pains  of  syphilis  are  usually  symmetrical ;  are  aggra- 
vated by  the  warmth  of  the  bed ;  are  generally  referred  to  the  superficial 
bones,  aud  do  not  exist  long  without  some  other  and  decisive  symptoms 
of  the  poison  manifesting  themselves. 

Chronic  rheumatism  and  gout  are  each  attended  with  such  marked 
collateral  disturbances  that  the  suspicion  of  their  presence  can  readily  be 
set  at  rest  or  sustained. 

INSANITY. 

The  principal  forms  of  insanity  are  commonly  considered  under  the 
head  of  Mania,  Monomania,  Melancholia,  Dementia,  Idiocy  and  Imbe- 
cility; to  which  may  be  added  emotional  and  impulsive  insanity,  which 
is  now  usually  admitted.  There  is  no  ground  for  recognizing  as  a  dis- 
tinct variety,  moral  insanity  (Flint). 

The  pathological  anatomy  of  insanity  is  thus  stated  by  Seguin  : — 

(Anaemia. 
Hyperemia. 
Serous  effusion. 
I.  Acute  Recent  Cases.  -j  Old  congestion. 

Hemorrhages  into  perivascular  sheaths. 
Changes  in    gray  matter  (not  demonstrable   under   the 
microscope). 

Congestion  or  anaemia. 
Atheroma  of  vessels. 

Membranes  changed,  diseased  and  thickened. 
Nerve  elements  degenerated  and  atrophied. 
General  atrophy  of  convolutions  ;  most  marked  in  ante- 
terior  convolutions. 


II.  Chronic  Insanity  and 
True  Dementia... 


Similar  to  preceding,  but  differs  in  distribution  of  lesions  ; 
particularly  in  neuralgia;   also  granular  vent  " 
changes.    Often  lesions  in  spinal  cord  co-exist, 
arachnoid  hemorrhage  not  a  frequent  change. 


ttt     r>  1  v>      1     •      J  particularly  in  neuralgia;   also  granular  ventricular 

III.  General  Paralysis..  <  changes.    often  lesions  in  spinal  cord  co-exist.    Sub- 

IV.  Syphilitic  Insanity. 


DISEASES  OF   THE   NERVOUS  SYSTEM.  121 

In  mania,  chronic  alcoholism  and  general  paralysis,  pa'Jiy-meningilis 
hemorrhagica  is  often  found.  Section  through  the  thickened  dura  reveals 
alternate  layers  of  tissue  and  coagulated  blood. 

Patients  under  twenty-five  years  of  age  seldom  have  chronic  insanity ; 
when  they  do  the  vascular  changes  are  less  marked ;  in  older  patients  the 
vessels  become  fatty  and  atheromatous.  The  capillaries  show  fatty 
change,  their  nuclei  being  first  affected ;  in  the  arteries  the  muscular  coat 
becomes  fatty.  Through  large  tracts  of  brain  granular  and  amyloid 
bodies  are  found.  Old  inflammatory  changes  in  the  meninges  are  quite 
common.     The  arachnoid  is  opaque  in  spots. 

The  causes  of  insanity  are  very  complex;  the  Physical  Causes  are 
thus  given  by  the  same  author : — 


Injuries  to  head. 


Concussion. 

Hemorrhages. 

Meningitis. 

Depressed  fracture. 

Abscess. 

Tumor. 

{Gummy  formations. 
Arteritis. 
Meningitis,  etc. 

-Tk  .  f  Malaria. 

Dyscrasiee <  AT        ....         , 

J  \  Narcotic  poisoning,  etc. 

A  i    t    !  (  Delirium  ebriosum. 

Alcohol {  n  ,.  •        , 

[  Delmuni  tremens. 

ri         t  f  Individual  venery. 

sexual  excess <  ■**■    ,     u  ,.  J 

\  Masturbation. 

{Uterine  difficulty. 
Vaginismus. 
Masturbation. 

The  Moral  Causes  are  misery,  depression,  emotions,  excitement, 
remorse,  fear,  grief,  religious  fervor,  excess  of  joy,  the  spirit  of  specula- 
tion, etc. 

The  two  forms,  mania  and  melancholia,  have  their  general  distinctions, 
as  follows : — 


L22 


DIFFERENTIAL   DIAGNOSIS. 


MANIA. 

Eyo  elated  ami  over  active. 

Joy  and  excitement  generally  pre- 
vail, sometimes  comic  emotions  char- 
acterize attacks. 

Over-ideation  and  over-action. 
Resulting  therefrom  incoherence  and 
delirium  and  violent  acts :  general 
restlessness. 

Insomnia. 


MELANCHOLIA. 

Ego  is  depressed  and  does  not  re- 
act normally  on  external  world. 

Sadness  and  fear;  religious  feel- 
ings strongly  developed. 

(few    motions 
Reduced  ideation.  <  and  even  abse- 
il lute  silence. 

f    Immobility 

-r>   -i       -,       ,.         relativeor total, 
Reduced    action.  <       , 

and  even  cata- 

(^  leptoid  state. 
Insomnia  (less  marked). 


PHYSICAL   SYMPTOMS. 


Increased  circulation. 
Increased  calorification. 
Increased  (?)  assimilation. 
Increased  voracity. 


Lessened  circulation. 
Lessened  calorification. 
Lessened  assimilation. 


The  earliest  symptoms  of  insanity  are  a  marked  change  in  the  habits ; 
proneness  to  excitement  and  loss  of  control ;  an  alteration  in  the  emotions ; 
failure  of  memory ;  untidiness  of  dress ;  insomnia  and  disturbing  dreams; 
unusual  loquacity  or  taciturnity;  defective  reasoning;  accepting  as  real 
various  fancies  and  illusions ;  a  furtive,  watchful  air ;  groundless  sus- 
picions of  those  around.  In  combination  with  these  mental  symptoms, 
the  pupils  are  often  dilated,  frequently  irregular,  and  sluggish  in 
obeying  the  stimulus  of  light;  and  a  pulse  hard,  rapid  and  variable,  100 
or  over,  a  pulse  which  is  not  equal  in  both  wrists  (Henry  Howard). 
The  tongue  is  pasty,  the  breath  foul,  and  the  bowels  constipated.  The 
digestion  is  impaired,  and  the  appetite  irregular  and  capricious.  There 
is  encroachment  of  the  senses  upon  each  other;  the  sense  of  sight,  for  in- 
stance, is  substituted  by  audition,  and  the  patient  will  describe  scenes 
with  the  greatest  minuteness  of  detail  as  occurring  in  the  neighborhood, 
even  to  the  color  of  clothing,  and  peculiarities  of  appearance  which  could 


DISEASES    OF  THE   NERVOUS   SYSTEM.  123 

only  be  learned  by  inspection,  but  which  he  knows,  because  he  "heard 
the  dogs  barking/'  or  the  noise  of  some  fancied  tumult.  The  hearing  of 
inaudible  voices  calling  opprobrious  names  is  even  popularly  recognized 
as  indicating  insanity.  Where  no  organic  changes  can  subsequently  be 
detected  in  the  brain,  we  are  forced  to  the  conclusion  that  there  is  cither 
some  non-recognizable  defect,  or  that  there  must  be  functional  disorder 
of  the  brain,  as  of  other  organs  in  the  economy. 


1  2  I  DIFFERENTIAL   DIAGNOSIS. 


CHAPTER  II. 

DISEASES  OF  THE  RESPIRATORY  APPARATUS. 

Diseases  of  the  Larynx. — Symptoms  of  Laryngeal  Diseases — Diag- 
nostic table  of  Acute  Laryngitis,  Chronic  Laryngitis,  Syphilitic  Laryn- 
gitis, Tubercular  Laryngitis,  Perichondritis,  Benign  Growths,  Malig- 
nant Growths,  and  Neuroses  of  the  Larynx — Croup  and  Diphtheria; 
Spasmodic  Croup,  Inflammatory  Croup,  Membranous  Croup,  and 
Diphtheria — Tonsillitis,  Catarrhal  and  Parenchymatous. 

Diseases  of  the  Lungs. — The  Regions  of  the  Chest — Normal  Differ- 
ences between  the  two  sides  of  the  Chest — Methods  of  Physiccd  Exami- 
nation— Normal  Respiratory  Sounds — Normal  Votes  Sounds — Abnor- 
mal Percussion  Sounds — Abnormal  Respiratory  Sowuls — Abnormal 
Voice  Sounds — General  Rules  for  Diagnosis — The  Forms  of  Phthisis 
(Catarrhal,  Fibroid,  Tubercular) — The  Diagnosis  of  Incipient  Phthisis 
— Diagnosis  between  Incipient  Phthisis  and  Bronchitis — Clinical  His- 
tory of  Phthisis — Acute  Phthisis  —  Syphilitic  Phthisis  —  Bronchitis, 
Acute  and  Chronic — Capillary  Bronchitis  competed  with  Pneumonia — 
Pneumonia  and  Pleurisy — Pleurisy  with  Effusion  and  Pneumonia  with 
Consolidation  compared — Diagnosis  between  Pneumonia  and  Pulmonary 
Apoplexy  —  Pulmonary  Embolism  —  Asthma  —  Pneumothorax  and 
Pneumo-hydrothorax  —  Emphysema,  Vesicular  and  Interlobular  — 
Cancer  of  the  Dung. 

In  studying  diseases  of  the  respiratory  apparatus,  we  find  in  addition 
to  the  disorders  of  the  lung  proper  and  its  serous  investment,  the  pleura, 
that  there  are  associated  organs  which  likewise  may  be  the  seat  of  disease; 
these  are  the  bronchi  and  trachea,  the  larynx,  pharnyx  and  upper  air 
passages.     We  commence  with  : — 

DISEASES  OF  THE  LARYNX. 

The  general  symptoms  of  laryngeal  diseases,  together  with  their  causes 
and  examples,  may  be  arranged  in  the  following  tabular  form : — 


DISEASES    OF  THE   RESPIRATORY   APPARATUS. 


125 


SYMPTOMS  OF  LARYNGEAL  DISEASES. 


Dysphonia. 


Aphonia. 


Dyspnoea. 


Stridor. 


Cough. 


Alteration  in  the  vocal 
cords  from  thickening, 
ulceration,  diminished 
tension,  morbid  growths, 
etc. 

Non-approximation  of  the 
vocal  cords,  either  me- 
chanical or  due  to  para- 
lysis of  some  of  the 
muscles  attached  to  them. 


Narrowing  of  the  orifice  of 
the  erlottis. 


Always  accompanied  by 
dyspnoea,  and  produced 
by  the  same  causes. 

Irritation  of  the  laryngeal 
mucous  membrane,  or 
the  nerves  of  the  larynx. 


EXAMPLES    OF  DISEASE. 


Acute  and  chronic   laryn- 
gitis. 
Laryngeal  phthisis. 
Papillomata,  etc. 

Cicatrization. 

Swelling  of  arytenoid  car- 
tilages. 

Tumors. 

Hysteria. 

Pressure  on  recurrent  la- 
ryngeal nerves,  etc. 

Paralysis  of  muscles  open- 
ing glottis. 

Laryngismus  stridulus. 

(Edema,  growths  and  cica- 
trices contracting  rima 
glottidis,  and  pressure 
external  to  larynx. 

As  in  dyspnoea. 


In  most  laryngeal  diseases 
it  is  of  a  peculiar  shrill, 
brazen  character. 


Laryngitis   has   been   divided   by  some   writers   into   the   followin| 
forms : — 


(Edematous  laryngitis. 
Catarrhal  laryngitis. 
Erysipelatous  laryngitis. 
Croupous  laryngitis. 


Diphtheritic  laryngitis. 
Syphilitic  laryngitis. 
Tubercular  laryngitis. 
Exanthematous  laryngitis. 


Traumatic  laryngitis. 

Among  authors  who  have  paid  especial  attention  to  this  subject,  there 
are  few  that  stand  higher  than  Mr.  Lennox  Browne,  of  London,  who 
in  his  recent  work  on  the  Diseases  of  the  Larynx  gives  the  diagnostic 
table  presented  in  the  following  pages. 


12(5 


D1KFEREXTIAL    DIAGNOSIS. 


SYMPTOMS. 


All    IK    LAB'S  CTGITIS. 


.'UK. IMC     I.AKVXi;iTlS. 


A.— Functional,  or  Subjective. 
Hoarse,  becoming  aphonic.   Hoarse,    uncertain,    easily 


VoK'K. 


RESPIRATION. 


Coi'Gir. 


Deglutition. 


Pa  ix  axd  Al- 
tered Sen- 
sation. 

Color. 


Form     and 
Texture. 


Position. 


External. 


Not  embarrassed  prior  to 
oedema ;  then  stridor,  dys- 
pnoea, and  even  apneea. 

Dry,  hard,  shrill,  metallic; 
aphonic;  on  exudation, 
moist. 


Painful  when  oedema  has 
taken  place,  or  from  as- 
sociated pharyngeal  in- 
flamation. 

Sensation  of  tightness  and 
constriction ;  tender  to 
external  pressure. 

B. — Physical,  or  Objective 

Intense,  uniformly  increas-  Partial  and  modified    sub 


fatigued. 


Seldom  embarrassed. 


Irritative,  with  slight  ex- 
pectoration of  glutinous 
pellets. 

Rarely  affected. 


Painless;  sense   of  fatigue 
after  vocal  exercise. 


ing  superficial  hypere- 
mia ;  translucent  on  event 
of  oedema. 

Thickening  and  stenosis 
from  oedema,  loss  of  tis- 
sue rare,  except  in  phleg- 
monous form. 


Unaltered. 


mucous  hyperemia. 


Occasionally  slight  erosion, 
never  ulceration,  thicken- 
ing or  narrowing1. 


Unaltered. 


C— Miscellaneous. 
Pharynx  usually  synchro- 1  Pharynx  usually  synchro- 
nously implicated.  nously  implicated. 


DISEASES    OF   THE    RESPIRATORY   APPARATUS. 


127 


SYPHILITIC    LARYNGITIS. 


TUBERCULAR    LARYNGITIS. 


Secondary.  Hoarse. 

Tertiary.  Characteristically  raucous; 
seldom  aphonic. 

Secondary.  Unchanged. 

Tertiary.  Increasing  embarrassment 
according  to  amount  of  stenosis. 

Secondary.  Slight  hacking'. 

Tertiary.  Infrequent,  with  but 
slight  expectoration,  unless  peri- 
chondritis supervene. 

Secondary.  Normal,  unless  deposit 
on  epiglottis  or  arytenoids. 

Tertiary.  Often  difficult ;  very  rare- 
ly painful. 

Characteristic  absence  of  pain  ex- 
cept when  cartilages  are  attacked. 


Sometimes  aphonic  in  earlier  stages ; 
completely  lost  in  advanced  dis- 
ease. 

Early  hurried  ;  greatly  embarrassed 
with  advance  of  disease. 

Greatly   influenced   by   amount   of 

lung  disease;  painful. 
Expectoration    variable ;    generally 

frothy. 

Extremely  difficult  and  painful, 
from  early  period  to  termination. 


Pain  only  experienced  in  functional 
acts. 


Secondary.  Mottled,  more  or  less 
symmetrical  hyperemia. 

Tertiary.  Hyperemia  of  portion  at- 
tacked prior  to  ulceration ;  per- 
manent infiltrated  appearance. 

Secondary.  Occasional  superficial 
ulceration  at  vocal  process  ;  slight 
general  submucous  infiltration. 

Tertiary.  Deep,  circumscribed  de- 
structive ulcers,  of  yellowish 
color,  followed  by  cicatricial  nar- 
rowing, occasionally  paralysis  and 
quasi-new  formations. 

Secondary.  Unaltered. 

Tertiary.  Deformity  from  intrinsic 
cicatrices  and  pharyngeal  out- 
growths. 

Secondary.  Pharynx  and  skin  gen- 
erally recently  implicated. 

Tertiary.  Seldom  synchronous  im- 
plication, but  usually  scars  of 
previous  similar  pharyngeal  ul- 
ceration, and  possible  adhesion. 


Anemia  followed  by  opaque  grayish 
color  ;  margins  of  ulcers  hypere- 
mia 


Solid  submucous  thickening  of  epi- 
glottis and  aryepiglottic  folds, 
elevation  and  ulceration  of  race- 
mose glands  giving  worm-eaten 
ulcers,  which  commingle  and  at- 
tack deeper  tissues. 


No  displacement;  tendeney  for 
thickened  parts  to  transgress 
boundaries  of  pharynx. 


Lungs  either  primarily,  synchro- 
nously, or  subsequently  involved. 
Generally  anaemia,  rarely  ulcera- 
tion of  pharynx.  General  emacia- 
tion. 


128 


DIFFERENTIAL   DIAGNOSIS. 


SYMPTOMS. 


l'KUUHONDHITIS. 


BENIGN  GROWTHS. 


A.— Functional,  or  Subjective. 


Voice. 

Respiration. 
Cough. 

Deglutition. 


Pain  and  Al- 
tered Sen- 
sation. 


Color. 


Form  and 
Texture. 


Position. 


External. 


Painful,  easily  fatigued, 
but  not  necessarily  im- 
paired. 

Variable,  according  to  car- 
tilage attacked. 

Generally  early  spasmodic ; 
with  caries  characteristic. 

Purulent  expectoration,  un- 
less abscess  is  encysted. 

Varying  from  dysphagia  to 
aphagia,  according  to 
pressure  on  gullet. 

Pain  variable  with  cause ; 
most  severe  in  gouty  form, 
but  not  then  constant. 


Very  variable,  from  slight 
hoarseness  to  complete 
aphonia,  even  in  the  same 
case. 

Seriously  embarrassed  in 
one-sixth  of  cases  ;  de- 
pends on  situation. 

Generally  limited  to  effort 
to  dislodge  foreign  body; 
may  be  expectoration  of 
atoms  of  growth. 

Only  impaired  in  rare  cases, 
in  which  epiglottis  or 
aryepiglottic  fold  is  in- 
volved. 

Characteristically  absent. 


B—  Physical,  or  Objective. 


Hyperemia  generally  limit- 
ed to  portion  attacked, 
sometimes  extending  to 
contiguous  vocal  cord. 

Ulceration  often  absent, 
substituted  by  encysted 
abscess,  causing  narrow- 
ing, compression  and  pa- 
ralysis. 

May  be  considerable  altera- 
tion of  supra  and  infra- 
glottic  space. 

C. — Miscellaneous. 

Occasional  constitutional  I 
manifestations. 


Variable  with  nature  of 
neoplasm ;  slightly  in- 
creased vascularity  of 
mucosa  generally. 

Varies  with  situation,  size, 
and  nature  of  growth, 
never  ulceration.  May 
cause  narrowing  and  pa- 
ralysis. 

Position  of  normal  parts 
seldom  changed. 


Nil. 


DISEASES   OF   THE   RESPIRATORY   APPARATUS. 


129 


MALIGNANT    GROWTHS. 


Impaired  by  mechanical  causes  when 
invaded  from  pharynx ;  may  be 
early  lost  in  primary  disease. 

Early  quickened  on  exertion ;  later 
paroxysmal  dyspnoea  from  ste- 
nosis or  compression. 

Not  necessarily  present;  expectora- 
tion scanty ;  occasionally  blood 
and  portions  of  neoplasm. 

Always  difficult  and  painful ;  often 
the  earliest  symptom. 


Lost  in  bilateral  paralysis  of  adduc- 
tors; impaired  in  other  paralyses; 
not  necessarily  in  spasm. 

Only  embarrassed  in  paralyses  of 
adductors  and  in  spasmodic  affec- 
tions. 

Paroxysmal,  when  recurrent  is  im- 
plicated and  in  spasmodic  affec- 
tions. 

But  slightly  impaired  or  unaffected. 


Ever  present  and  severe,  extending  :  Only  experienced  when  sensory  sys- 


upward  to  the  ears,  and  to  sym- 
pathetic glandular  enlargements. 


tern  affected.  Diminished  sensa- 
tion in  motor  paralyses  and  in 
anaesthesia. 


Increasing  localized  vascularity  tend- 
ing to  lividity  in  any  part  except 
vocal  cords  or  ventricles,when  neo- 
plasm is  whitish-gray  or  pale  rose. 

May  cause  compression,  narrowing 
and  paralysis  before  ulceration, 
which  is  always  accompanied  by 
thickening.  Extensive  indolent, 
gray,  greenish,  or  almost  black 
ulcers. 

Early  displacement,  especially  when  !  Paralyzed  cord  not  displaced, 
invading  from  pharynx,  and  when  j      often  fixed  in  one  position, 
neighboring;  glands  enlarged. 


In  paralysis  of  abductors,  occasional 
vascularity  of  affected  vocal  cords. 


Form  of  glottis  varying  with  nature 
of  paralysis,  without  extrinsic 
thickening. 


but 


Glandular  infiltration,  but  complete   Sympathetic  functional  disturbances 


immunity  of  other  organs  of  body 
from  similar  disease  both  prior 
and  subsequent  to  appearance  in 
laryngo-pharynx.  General  ema- 
ciation. 

9 


in  other  organs,  or  organic  disease 
of  cardiac  or  lymphatic  system, 
or  associated  cerebral  disease  or 
chronic  toxaemia. 


L30  DIFFERENTIAL    DIAGNOSIS. 

The  chronic  laryngitis  of  syphilis  cannot  with  certainty  l>e  distinguished 
from  the  other  forms  of  chronic  laiyngitis  withoul  inquiry  into  the  his- 
tory of  the  case;  although  a  probable  diagnosis  may  be  made  where  treat- 
ment by  anti-syphilitic  remedies  is  successful. 

In  tertiary  syphilis  there  is  deep  and  extensive  ulceration,  not  neces- 
sarily preceded  by  thickening-;  the  epiglottis  is  attacked  early,  the  ulce- 
ration is  often  followed  by  cicatrization  and  contraction,  causing  stenosis 
of  the  larynx. 

In  the  study  of  laryngeal  diseases  the  use  of  the  laryngoscope  is  indis- 
pensable to  correctness  of  diagnosis.  We  take  it  for  granted  that  the 
practitioner  is  conversant  with  this  instrument,  and  the  proper  methods 
of  employing  it.  It  reveals  the  physical  or  objective  local  symptoms, 
which  are  of  much  more  value  than  the  subjective  ones  derived  from  the 
patient's  statements. 

CROUP  AND  DIPHTHERIA. 

The  general  sign  common  to  this  class  of  diseases  is  a  laryngeal  stridor  ; 
they  are  divided  into  those  where  there  is  a  formation  of  false  membrane 
and  where  there  is  uot. 

Without  false  membrane. 

Spasmodic  croup  or  laryngismus  stridulus. 
Imflammatory  croup,  simple  catarrhal  laryngitis. 

With  false  membrane. 

True  croup  or  membranous  croup. 
Diphtheria. 

The  diagnosis  between  spasmodic  and  inflammatory  croup  is  as  follows : — 
SPASMODIC  CROUP.  INFLAMMATORY  CROUP. 

Onset  sudden,  usually  at  night,  I  Onset  gradual,  with  sore  throat, 
with  few  or  no  prodromal  symp-  j  tickling,  tenderness  of  larynx  and 
toms.  catarrh. 

Difficulty  of  swallowing  absent  or  Increasing  difficulty  in  swallow- 
temporary,  ing. 

Febrile" symptoms  absent,  or  much  ;  Flushed  face,  hot,  dry  skin,  high 
less  marked.  temperature  (105°),  frequent  pulse. 

Larynx  little  affected.  Mucous  membrane  of  larynx  red 

I  and  swollen,  sometimes oadematous. 

Intermission  complete,  or  nearly  Remission  but  slight;  local  symp- 
so,  between  the  croupous  attacks.        toms  and  pyrexia  continue. 

Very  rarely  fatal.  In  early  life  a  dangerous  disease. 


DISEASES   OF   THE   RESPIRATORY   APPAKATUS. 


131 


Very  considerable  differences  of  opinion  are  entertained  as  to  the 
formidable  and  frequent  disease  diphtheria.  Some  maintain  its  identity 
with  membranous  croup,  others  with  scarlatina,  while  others  believe  it 
to  be  a  malady  distinct  in  origin,  course,  result  and  treatment  from  them 
both.  The  last  mentioned  opinion  appears  to  have  the  most  adherents, 
and  the  most  facts  on  its  side.  The  differences  between  the  diseases 
are  fully  set  forth  in  the  table  subjoined : — 

MEMBRANOUS  CROUP.  DIPHTHERIA. 

It  is  a  local  complaint.  Rarely 
or  never  occurs  after  puberty. 

It  is  not  contagious.  Type 
sthenic. 

Commences  with  a  cough,  catarrh 
and  hoarseness ;  little  or  no  sore 
throat  and  difficulty  of  swallowing. 
Cough  shrill,  metallic;  breathing 
stridulous  from  the  outset. 


The  membranous  affection  begins 
m  the  larynx  and  extends  to  the 
throat. 

Fauces  injected  but  rarely  swol- 
len, and  generally  without  exudation. 

Exudation  never  cutaneous. 

No  swelling  of  the  submaxillary 
glands. 

Epistaxis  and  albuminuria  absent. 

Little  and  often  no  prostration  of 
the  general  strength. 

Improves  under  emetics,  local 
counter-irritants,  expectorants  and 
depressants. 

Is  never  followed  by  paralysis. 

Rarely  fatal.  Death  from  apnoea. 
Blood  not  changed.  Spleen  not 
affected. 


Is  a  general  disease,  common  to 
all  ages. 

It  is  decidedly  contagious.  Type 
asthenic. 

Commences  with  a  chill,  sore 
throat,  difficulty  of  swallowing ;  but 
neither  hoarseness  nor  cough  at  the 
outset.  Stridulous  breathing  a  late 
symptom. 

The  membranous  affection  begins 
in  the  throat  and  thence  extends  to 
the  larynx  (Da  Costa). 

Fauces  injected,  swollen  and  pre- 
senting exudation. 

Exudation  often  cutaneous. 

Submaxillary  glands  swollen. 

Epistaxis  and  albuminuria  fre- 
quent. 

Considerable,  often  extreme  pros- 
tration. 

Demands  a  stimulating  and  sus- 
taining treatment. 

Subsequent  paralysis  not  infre- 
quent. 

Frequently  fatal.  Death  usually 
by  asthenia.  Blopd  after  death  usu- 
ally fluid  and  dirty  brown.  Spleen 
enlarged  and  softened  (J.  \V.  How- 
ard). 


L32 


DIFFERENTIAL    DIAGNOSIS. 


T(  )XSILLTTIS. 

Inflammation  of  the  tonsils  assumes  two  forms,  in  one  of  which,  the 
catarrhal  form,  the  inflammation  extends  to  the  secreting  tissues  and 
Lining  membrane  of  the  crypts,  and  in  the  other  to  the  parenchymatous 
structure  of  the  gland.  These  two  forms  differ  widely  in  cause,  in 
symptoms,  in  treatment  and  result.  Their  diagnostic  symptoms,  as  tabu- 
lated by  Mr.  Arthur  Treiierne  Norton,*  are  as  follows: — 


CATARRHAL  TONSILLITIS. 

Is  a  mucous  inflammation  of  three 
or  four  days'  duration. 

Is  caused  by  exposure  to  draft, 
damp,  cold,  etc. 

Prostration  and  often  profuse  per- 
spiration. Pulse  small  and  quick. 
Never  runs  on  to  abscess. 

Both  tonsils  affected. 

Lacunae  filled  with  masses  of  mor- 
bid secretion  resembling  ulcers. 

No  oedema  around. 

Treatment.  —  Tonics,  stimulants 
and  astringent  gargles. 


PARENCHYMATOUS  TONSILLITIS. 

Is  a  fibrous  inflammation  of  from 
two  to  four  weeks'  duration. 

Often  caused  by  neighboring  in- 
flammation, cutting  wisdom  teeth. 

High  fever,  with  hot,  dry  skin. 
Pulse  strong  and  hard.  Commonly 
forms  an  abscess. 

Rarely  both  affected. 

Often  covered  with  lymph,  but 
no  collection  of  secretion  in  lacuna?. 

Extensive  oedema. 

Treatment.  —  Antiph logistics  and 
depressants,  but  never  gargles,  ex- 
cept in  the  form  of  warm  water. 


DISEASES  OF  THE  LUNGS. 

In  passing  from  the  consideration  of  the  disorders  of  the  upper  air- 
passages  to  the  diseases  of  the  lungs,  it  is  thought  advisable  to  discuss 
somewhat  in  detail  the  several  methods  of  examination  of  the  patient, 
and  to  consider  systematically  the  various  objective  phenomena  presented 
by  them  as  introductory  to  the  study  of  their  alterations,  which  are  char- 
acteristic of  certain  diseases.  Palpation,  mensuration,  auscultation  and  per- 
cussion, therefore,  furnish  evidence  of  great  clinical  importance,  which 
may  be  considered  collectively  under  the  head  of  physical  diagnosis. 

The  study  of  Physical  Diagnosis  necessarily  commences  with  a  correct 
appreciation  of  the  location  of  organs,  their  functions  and  physical  charac- 
*British  Medical  Journal,  Jan.,  1874. 


DISEASES    OF    THE    RESPIRATORY    APPARATUS.  166 

ters  in  health;  to  which  must  follow  a  clear  understanding  of  the  specific 
and  peculiar  alterations  which  each  of  these  elements  undergoes  when  it 
becomes  a  factor  in  disease.  To  acquire  this,  we  give  on  the  following 
pages  tabular  arrangements  of  the  following  subjects : — 

I.  The   Regions    of  the    Chest,   their    Contents   and    Normal    Signs. 

II.  The  Normal  Differences    between    the   two    Sides   of   the    Chest. 

III.  Methods  of  Physical  Examination.  IV.  Normal  Respiratory 
Sounds.  V.  Normal  Voice  Sounds.  VI.  Abnormal  Resonance  on 
Percussion,  and  its  Causes.  VII.  Abnormal  Intensity,  Rhythm  and 
Quality  of  Respiratory  Sounds.  VIII.  Abnormal  (dry)  Respiratory 
Sounds.  IX.  Abnormal  (moist)  Respiratory  Sounds.  X.  Abnormal 
(amphoric)  Respiratory  Sounds.     XI.   Abnormal  Voice  Sounds. 

I.  THE  REGIONS  OF  THE  CHEST. 


1.  Cervical. 

2.  Supra-clavicular. 

3.  Clavicular. 


4.  Subclavian. 


5.  Mammary. 


contents. 


Vesicular  struc- 
ture of  lung. 
Heart  on  left 
side. 


resonance  on 

percussion  in 

health. 


Larynx   and   tra- 
chea. 

Apex  of  lung.  Clear. 


Clavicles  and  ves-    Clear, 
icular  structure 
of  luna;. 


Vesicular      struc-    Clear, 
ture  of  lung. 


Clear  on  right 
side.  Dull  on 
left  in  greater 
part  of  region. 


auscultation  in 
health. 

Tracheal  breathing 
and  voice. 

Very  pure  vesicular 
murmur  (scarcely 
audible)  :  voice 
scarcely  uudible. 

Pure  vesicular  mur- 
mur and  scarcely 
audible  voice,  ex- 
cept at  the  sternal 
end,  where  there  are 
bronchial  breathing 
and  bronchophony. 

Pure  vesicular  mur- 
mur and  scarcely  au- 
dible voice.  Heart 
sounds  on  left  side 
below. 

Pure  vesicular  mur- 
mur above.  Heart 
sounds  below  on  left 
side,  and  feeble  vesi- 
cular murmur  o  n 
right.  Voice  scarce- 
ly audible. 


134 


DIFFERENTIAL    DIAGNOSIS. 


I.  THE  REGIONS  OF  THE  CHEST— {Continued). 

REGION. 

CONTENTS. 

RESONANCE    ON 

PERCUSSION    IN 

HEALTH. 

ai  SCULTATION  IN 
HEALTH. 

6.  Infra-mammary. 

Anterior    portion 

Generally  tympa- 

1 ►istincl    re  si  c  u  1  a  r 

of  base  of  lung. 

nitic     o  n      left 

murmur.      V  o  i  c  e 

Stomach  below, 

side  ;     dull    on 

scarcely  audible. 

on    left    s  i  il  e, 

right. 

liver  on  right. 

7.    SlTEKIOR  STERNAL. 

Division    of  tra- 

Clear. 

Bronchial      breathing 

chea,  aorta,  and 

and  brOnchopony. 

great  vessels. 

8.  Inferior  sternal. 

Anterior   medias- 

Clear above  :  tym- 

Pure   vesicular    mur- 

tinum   above. 

panitic  below. 

mur  al>o\ e.  becom- 

Stomach below 

ing  feeble  be  1  0  w  . 
Voice  scarcely  au- 
dible. 

'.i.   Axillary. 

Vesicular      struc- 

Clear. 

Pure    vesicular    mur- 

ture of  lung. 

mur.  Voice  scarcely 
audible. 

10.   Lateral. 

Vesicular      struc- 

Clear above  ;  dull 

Pure    vesicular    mur- 

ture of  lung. 

below  on   right 

mur.  Voice  scarcely 

side. 

audible. 

11.  Supra-scapular. 

Apex  of  lung. 

Clear. 

Pure  vesicular  mur- 
mur. Voice  scarcely 
audible. 

12.  Scapular. 

Vesicular      struc- 

Rather less  clear. 

Pure    vesicular    mur- 

ture of  lung. 

mur.  Voice  scarcely 
audible. 

13.  Inter-scapular. 

Roots  of  hum  and 

Clear. 

Bronchial      breathing 

large  bronchi. 

and  bronchophony. 

14.    IXFRA-SCAPCLAR. 

Base  of  lung. 

Clear. 

Very  pure  vesicular 
murmur.  Voice 
scarcely  audible. 

II.  NORMAL  DIFFERENCES  BETWEEN  THE  TWO  SIDES  OF  THE 


CHEST.     (A.  H.  Smith.) 


/'  reussion  Resonance. 
Vocal  lli'siinmue. 
Bronchial  Whisper. 
Inspiratory  Sound. 


Expiration. 


RIGHT  SIDE. 


Decidedly  greater  on  the  right 

side. 
More  intense  than  on  the  left, 

and  a  little  lower    in  pitch. 


Fn  (juently  prolonged  i  n 
healthy  individuals  on  this 
side. 


LEFT    SIDE. 


A  little  more  intense  than  on 
the  right  side. 


A    little    lower  on    this    side, 
more   vesicular  in   quality, 

and  lower  in  pitch. 


DISEASES    OF   THE    RESPIRATORY   APPARATUS. 
III.    METHODS  OF  PHYSICAL  EXAMINATION. 


1 35 


METHODS  OF  EXAMI- 
NATION. 

1.  Inspection. 


2.  Palpation. 
{Application  of 
the  Hand. ) 


5.  Mensuration. 
(a)  Of  Size. 
(6)  Of  Movement. 


4.  Percussion. 


5.  Auscultation. 


6.  Succussion. 


snows. 


Form,  symmetry  and  capacity 
of  the  chest. 

Local  bulging,  depression  or 
l'etraction. 

Conditionof  intercostal  spaces. 

Character  and  frequency  of 
respiratory  movements. 

Comparative  size  and  degree 
of  movement  of  the  two 
sides. 

Position  and  extent  of  im- 
pulse of  heart. 

Comparative  movement  of  the 
two  sides. 

Vibration  communicated  to 
the  chest  wall  by  the  voice 
(vocal    vibration   or    vocal 

■    fremitus  ). 

Force  of  the  heart's  impulse. 

Occasionally  certain  morbid 
phenomena,  as  pleural  and 
pericardial  friction,  valvular 
thrill. 

Comparative  size  of  the  two 
sides  of  the  chest. 

Actual  and  comparative  move- 
ment of  the  chest  in  respi- 
ration. 

Degree  of  resonance  in  vari- 
ous parts  of  the  chest. 
Extent  of  cardiac  dullness. 


Character  of  respiratory  mur- 
mur. 
Abnormal  respiratory  sounds. 
Heart  sounds. 
Abnormal  cardiac  sounds. 

Presence   of  air  and  fluid  in 
pleural  cavity. 


[INSTRUMENTS    USED. 


Graduated  tape. 

Cyrtometer. 

Dr.  Sibson's  stethometer. 

Dr.  Quain's  " 

Dr.  Edward's  chest  calipers. 

Dr.  Hutchinson's  spirometer. 

Plessor — A  hammer  tipped  with 

india  rubber. 

The  first  and  second  fingers 

of  the  right  hand  will  be  found 

to  be  the  best  plessor. 
Pleximeter — A  thin  plate  of  ivory 

or  bone. 

The   forefinger    of   the    left 

hand  will  be  found  to  be  the 

best  pleximeter. 

Stethoscope  —  Made  of  wood, 
metal,  or  vulcanite. 

Dr.  Scott  Alison's  bin-aural  steth- 
oscope. 


136 


DIFFERENTIAL    DIAGNOSIS. 


I'i.ki  ossion  may  be — Immediate. — Where  the  chest  is  struck  direeffy, 
without  tin1  interposition  of  any  pleximeter. 

(2)  Mediate. — Where  an  instrument  termed  a  pleximeter  is  interposed 
between  the  chest  and  the  substance  with  which  the  stroke  is  made.  Tin's 
may  be  either  a  thin  plate  of  ivory  or  hone,  or,  still  better,  the  first  and 
second  fingers  of  the  left  hand. 

AUSCULTATION  may  he — Immediate. — Where  the  car  is  applied  directly 
to  the  walls  of  the  chest. 

(2)  Mediate. — Where  the  stethoscope  is  interposed  between  the  ear  and 
the  walls  of  the  chest. 

IV.  NORMAL  RESPIRATORY  SOUNDS. 


VesK  ILAIi  BREATHING. 


Puerile  Breathing. 


Bronchial  Breathing. 


Tracheal    ^ 

or  V  Breathing. 

Laryngeal  j 


SITUATION'    WHERE    HEARD. 


All  over  the  chest  except  the  upper  part 
of  the  sternum  and  the  space  between 
the  scapulae,  the  inspiratory  sound  be- 
ing louder,  and  three  or  four  times 
longer  than  the  expiratory. 

Is  the  loud  vesicular  breathing  of  chil- 
dren, audible  over  the  same  parts  of  the 
chest  as  the  ordinary  vesicular  breath- 
ing. 

Upper  part  of  the  sternum  and  the  space 
between  the  scapuke  in  many  healthy 
persons. 

Over  the  trachea  and  larynx. 


V.  NORMAL  VOICE  SOUNDS. 


Ordinary    Vocal    Reso 

XAN'CE. 


SITUATION    AND    CHARACTER. 


Is  the  voice-sound  heard  over  the  pulmo- 
nary regions  where  vesicular  murmur  is 
audible.  A  muffled,  diffused  sound ; 
the  articulation  of  the  voice  is  not  ap- 
preciable. 

Nai  ural    Bronchophony.   Heard  over  the  upper  part  of  the  sternum, 

and  between  the  scapuhc  in  a  certain 
number  of  healthy  persons.  A  more 
distinct  and  concentrated  sound  than  the 
last  variety. 


DISEASES    OF    THE    RESPIRATORY    APPARATUS. 


VM 


V.  NORMAL  VOICE  SOUNDS— {Coniinved). 


SOUNIJ. 

SITUATION   AM)    CHARACTER. 

Laryngophony  and 
Trachophony. 

Voice-sounds  heard  over  the  larynx  and 
trachea.      Voice     transmitted     imper- 
fectly articulated  to  the  ear  of  the  <>!)- 
server,  with  so  much  loudness  and  con- 
centration as  even  to  be  painful. 

VI.  ABNORMAL  RESONANCE  ON  PERCUSSION. 


RESONANCE. 


Diminished 

in 

various  degrees, 

or  altogether 

Absent. 


Increased. 


Tympanitic. 
Amphoric. 

Box-like. 

Cracked-pot 
Sound. 


'Deficiency  of  air,  or  ab- 
normal deposit,  in  the 
lung  beneath  the  part 
percussed,  or  solid  or 
liquid  matter  between 
the  walls  of  the  chest 
and  the  lung  contain- 
ing air;  or  extreme 
distention  of  the  chest 
with  air. 


Air  increased  in  quantity, 
or  air  in  pleural  cavity. 


A  large  cavity  (or  con- 
ditions resembling  it) 
with  very  tense  walls, 
containing  air. 

Air  expelled  from  cavity 
by  sudden  pressure. 


EXAMPLES    OF   DISEASE. 


Pneumonia,  first  stage. 
Phthisis;  contracted  lung, 

with  thickened  pleura. 
(Edema  and   congestion 

of  lung. 
Tumors. 

Collapse  of  lung. 
Pneumonia,   second  and 

third  stages. 
Intra-thoracic    tumors 

and  aneurisms. 
Effusions     into    pleural 

cavity,  or  its  extreme 

distention  by  air. 

Emphysema. 

Tubercular  cavity,  hav- 
ing thin  walls,  and  sit- 
uated near  the  surface. 

Pneumothorax. 

Extreme  emphysema. 

Upper  part  of  lung  com- 
pressed by  fluid  below. 

Pneumothorax. 

Cavities. 

Cavity  of  considerable 
size,  with  large  bron- 
chus opening  into  it, 
mouth  of  patient  being 
open  during  percussion 


138 


DIFFERENTIAL    DIAGNOSIS. 


VII.  A.BXOKMAL  INTENSITY,  RHYTHM.  AND  QUALITY  OF 
RESPIRATORY  SOUNDS. 


r  Feeble  Breathing. 


S        EXTINCT   BREATHING. 


Pcerile,  or 

SUPPLEMEN- 
TARY 


Breathing. 


Inter- 

III   1TED, 

Jerking, 

Cogged- 
wheel 


-  Breathing. 


Prolonged  Expiration. 


CHIEF    CAUSES. 


Air  entering  the 
air-cells  in  di- 
minished quan- 
tity and  force. 


The  presence  of 
a  non-conduct- 
ing medium  be- 
tween the  lung 
and  the  chest- 
wall,  or  some 
impediment  to 
the  entrance  of 
air  into  the 
bronchi. 

Air  entering  the 
air-  cells  w  i  t  h 
increased  rap- 
idity and  force. 


Respiratory 
movements  re- 
stra  i  n  e  d  by 
pain,  or  mental 
emotion,  o  r 
some  tempo- 
rary local  ob- 
struction of  the 
air-tubes. 

Loss  of  elasticity 
in  the  lung  tis- 
sue. 


condition   op 

ORGANS. 

Lu  n  g  partially 
solidified  either 

by  increase  of 
solid  or  fluid 
within  it,  or  by 
pressure  from 
without;  dilata- 
tion of  the  air- 
vesicles;  in 
some  cases 
lungs  not  affec- 
ted. 

Lung  solidified 
by  pressure  up- 
on its  surface  ; 
plug  of  mucus, 
fibrinous  exu- 
dation or  for- 
eign body  in 
the  bronchi,  or 
tumor  compres- 
sing the  bron- 
chi. 

Healthy,  but  ex- 
aggerated in 
function. 


Varies  with  the 
disease  causing 

it. 


Thinning  of  the 

walls  of  the  aii- 
vesicles,  with 
dilatation  and 
destruction  o  f 
the  alveolar 
septa. 


EXAMPLES  OF 
DISEASE. 

Incipient 
phthisis. 

Bronchitis. 
Pneumonia,  first 

stage. 
Tumors. 
Pleurisy. 
Kinphysenia. 
Pleurodynia. 


Pleuritic    effu 
sion. 
Pneumothorax. 

Plastic    bronch 

itis. 
Tumors. 
Foreign  body  in 

bronchus. 


Disease  of  oppo- 
site lung  or  of 
other  parts  of 
the  same  lung. 

Met  with  as  a 
normal  condi- 
tion in  child- 
hood. 

Pleurodynia. 
Pleurisy. 
Debility,    with 
palpitation. 

Hysteria. 
Incipient 

phthisis. 
Spasmodic 

asthma. 
Emphysema. 


DISEASES    OF   THE    RESPIRATORY    APPARATUS. 


139 


'  ExAGGER-  ~\ 

ated,       >  Breathing. 
Coarse     J 


Blowing,  " 
Tubular, 
or  Bron- 
chial Ca- 
vernous J 
Amphoric  Breathing. 


-  Breathing. 


chief  causes. 


condition  of 
organs. 


'Lung   not    solidi- 
fied (soft  sound). 


ABNORMAL   INTENSITY,  IMIYTIIM    AND   QUALITY   OF    RESPIRATORY 

SOUNDS— (Continued). 

EXAMPLES    of 

MS  EASE. 

Generally  eon- 
istent     with 
health      a  n  d 
supplement- 
ary. 

Eeard in  cases 
of  uraemia  and 
other  blood 
poisoned  dis- 
eases, and  in 
hysteria  and 
nervous  dis- 
eases. 

Incipient 

phthisis. 

Phthisis. 

Pneumonia. 

Tumors. 

Tubercularand 
other  cavities. 

Pneumotho- 
rax. 

Dilated  bron- 
chi. 

Large  cavities. 


Increased  fric- 
tion in  the  air- 
cells  and  small- 
er bronchial 
tubes. 


Friction  of  air 
in  the  bronchial 
tubes,  or  in  cav- 
ities of  the  lung. 

Air  passing  into 
a  large  cavity 
with  dense 
walls. 


Lung  solidified  or 
bronchial     tubes 
obstructed(harsh 
sound). 
Condensation  of  the 
lung    between   the 
chest  wall  and  the 
larger    bronchi   or 
cavities. 
Cavities  with  dense 
walls. 


VIII.      ABNORMAL  DRY  RESPIRATORY  SOUNDS. 


SOUND. 

SITUATION. 

CAUSE. 

EXAMPLES    OF 
DISEASE. 

SlBILUS. 

Lesser  bronchial 

Vibration  of  thick  mucus  attached 

Bronchitis. 

tubes. 

to  the  wall  of  the  tube,  or  con- 

Emphvsema. 

traction   of  the  tube,  due  either 

Asthma. 

Rhonchus. 

Larger  bronchial 

to  swelling  or  spasm  ;  not  easily 
removed  by  cough. 
Vibration  of  thick  mucus  in  tubes  ; 

Bronchitis. 

tubes. 

generally     easily    removed     by 

cough. 

Dry  Crackling. 


Humid  Crackling. 
Pleural    Friction 
Sound. 


Creaking  Sound. 


CLICKING  OR 
Smaller  Bronchi. 


Smaller  Bronchi. 

Layers     of 
pleura. 


CRACKLING. 

'  Separation  of  the  ad- 
herent walls  of  the 
bronchi  —  the  dry 
tending  to  pass  in- 
to the  moist  variety. 
Movement  of  opposed 
surfaces  of  pleura 
roughened  by  the  de- 
posit of  lymph  or  tu- 
bercle. 


Incipient  phthisis. 


Phthisis,  first  stage. 

Pleurisy  before  ef- 
fusion has  com- 
menced, or  after 
absorption  of 
the  fluid. 


140 


DIFFERENTIAL    DIAGNOSIS. 


IX. 

m:Xui;mai.  moist  i;i:si'h:at<>i;y  SOUNDS. 

EXAMPLES   OF 

SOUND. 

SITUATION. 

CAUSE. 

DISEASE. 

Crepitant  1!  u.e. 

Air-vesicles. 

Opening  up  of  collapsed 

Pneumonia  in  first 

i  /■  ine  or  pneumo- 

air-cells, or  separation 

stage. 

nic  crepitation  I. 

of  their  adherent  walls 

CEdema  of  lungs. 
Collapse. 

S  0  B  CB  K  P  IT  A  XT 

Smaller      bronchial 

Bursting  of  air  bubbles 

Capillary  bronchi- 

Rale     {Medium 

tubes. 

in  fluid. 

tis. 

crepitation). 

Phthisical  bronchi- 
tis. 
Resolution  ofpneu- 

tnoma. 

CEdema  of  lung. 

Pulmonary        apo- 

Mucous Rale 

Larger     tubes    and 

Bursting  of  air-bubbles 

plexy. 
Phthisis. 

i  L.n-'ie    Crepita- 

small  or  moderate- 

in  fluid. 

Bronchitis. 

tio  i. 

sized  cavities. 

Haemoptysis. 

Gurgling  or  Ca- 

Large   cavities    (or 

Bursting  of  air-bubbles 

Phthisis  (3d  stage). 

vernous  Rale. 

number     of    small 
cavities). 

in  fluid. 

Bronchiectasis. 

Churning  Sound. 

Lung  in   a  state  of 

Abscess  of  lungs. 

disorganization. 

( i-angrene  of  lung. 

X.     ABNORMAL  AMPHORIC  SOUND. 


Sim. ash     on    Suc- 
CUSSION. 

Bell  Sound. 


Amphoric     Echo 

and    -M  E TALLIC 

Tinkling. 


SITl'ATION. 


Cavity  of  pleura  or 
large  cavity. 

Cavity  of  pleura. 


Cavities. 


I'AI'SF.. 


Pneumothorax 

with  effusion. 
Very  large  cavity. 
Pneumothorax. 


Sudden  disturbance  of 
air  and  fluid  existing 
together. 

Auscultation  of  an  air- 
containing  cavity  wh  lie 
an  assistant  uses  two 
coins,  one  as  a  ham- 
mer, the  other  as  a 
pleximeter. 

Vibration  of  air  in  large    Phthisis  with  very 


EXAMPLES    OF 
DISEASE. 


cavities  with  tense 
walls.  The  former 
may  be  produced  by 
rales  and  rhonchi  in 
the  chest,  by  the  voice, 
and  by  the  act  of 
coughing;  the  latter 
requires,  in  addition,  a 
little  fluid  at  the  bot- 
tom of  the  cavity,  set 
in  vibration  by  a  mo- 
mentary impulse,  such 
as  ih"  fall  of  a  drop  of 
fluid,  and  is  essentially 
the  echo  of  a  bub- 
ble. 


large  cavities. 
Pneumothorax 
with  effusion. 


DISEASES   OF   THE   RESPIRATORY    APPARATUS. 
XL  ABNORMAL  VOICE  SOUNDS. 


1  II 


SOUND    OF   VOICE. 


Feeble  or  absent 
Vocal  Reso- 
nance. 


Exaggerated    V  o 
cal  Resonance. 


Bronchophony. 


Pectoriloquy. 


Amphoric    R  e  s  o  • 
nance  or  Echo. 


CEgophony. 


CHARACTER  OP 

SOUND. 


The  obscure  hum- 
ming or  buzzing 
noise  heard  over 
the  normal  chest 
either  very  feeble 
or  altogether  ab- 
sent. 

Voice  sounds  unal- 
tered in  quality  or 
distribution,  but 
louder  and  of 
greater  intensity 
than  natural. 

Voice-sounds  heard 
louder,  clearer, 
and  more  vibra- 
tory than  natural, 
but  unattended 
with  articulation 
or  tactile  sensa- 
tion to  the  ear. 

Voice-sounds  d  i  s  - 
tinctly  articulated 
and  concentrated 
and  as  if  spoken 
into  the  end  of  the 
stethoscope. 

A  ringing  metallic 
sound  resembling 
that  produced  by 
speaking  into  an 
empty  jar. 

A  tremulous  vibra- 
tory sound  resem- 
bling the  bleating 
of  a  goat,  or  the 
nasal  Punchinello 


CAUSE. 


Primary  bronchus 
obstructed;  non- 
conducting m  e  - 
dium  in  pleura  or 
rarefied  condition 
of  lung. 

Increased  resound- 
ing or  conducting 
power  due  to  con- 
solidation of  the 
lung,  or  to  the  for- 
mation of  abnor- 
mal spaces. 

Much  increased  re- 
sounding or  con- 
ducting power. 


Large  abnormal  cav- 
ity   with   dense 

walls. 


The  voice  reverbe- 
rating in  a  large 
cavity  with  a  small 
aperture. 

A  thin  layer  of  fluid 
in  the  pleural  cav- 
ity, with  condensed 
lung  behind. 


EXAMPLES    OP 
DISEASE. 

Tumors  compre 

or  foreign  body  in 

bronchus. 
Pneumothorax. 
Pleuritic  effusion. 
Emphysema. 

Incipient  phthisis, 
Dilatation    of   bron- 
chi. 


Cavities  due  to  phthi- 
sis or  dilatation  of 
the  bronchi. 

Consolidation  of  the 
lung  resultingfrom 
collapse,  hasmor- 
rhagic  infarctions, 
pneumonia,  phthi- 
sis, cancer,  etc. 

Phthisis,  dilated 
bronchi,  etc. 


Phthisis. 
Pneumothorax. 


Pleurisy    with    effu 
sion. 


1-12  DIFFERENTIAL   DIAGNOSIS. 

The  quality  and  pitch  of  the  vocal  resonance  varies  g-rcatly  in  different 
individuals,  and  as  a  diagnostic  aid  is  almost  useless  in  women.  Whis- 
pering, sometimes,  will  give  more  satisfactory  results  than  the  loud  "one, 
two,  three,"  that  is  so  constantly  heard  in  our  clinical  amphitheatres. 
The  use  of  a  small  reed  whistle,  such  as  is  found  in  childrens'  rubber 
toys,  will  often  give  more  uniform  effects  for  comparison  than  the  voice. 

GENERAL  RULES  FOR  THE  DIAGNOSIS  OF  DISEASES 
OF  THE  RESPIRATORY  SYSTEM. 

The  late  Dr.  John  Hughes  Bennett  laid  down  the  following  prac- 
tical rules : — 

1.  A  friction  murmur  heard  over  the  pulmonary  organs  indicates  a 
pleuritic  exudation. 

2.  Moist  or  dry  rales,  without  dullness  on  percussion,  or  increased  vocal 
resonance,  indicate  bronchitis. 

3.  Dry  rales  accompanying  prolonged  expiration,  with  unusual  reso- 
nance on  percussion,  indicate  emphysema. 

4.  A  moist  rale  at  the  base  of  the  lung,  with  dullness  on  percussion, 
and  increased  vocal  resonance,  indicates  pneumonia. 

5.  Harshness  of  the  respiratory  murmur,  prolonged  expiration  and  in- 
creased vocal  resonance  confined  to  the  apex  of  the  lung,  indicates  in- 
cipient phthisis. 

6.  Moist  rales  with  dullness  on  percussion,  and  increased  vocal  reso- 
nance at  the  apex  of  the  lung,  indicate  either  advanced  phthisis  or  pneu- 
monia, generally  phthisis. 

7.  Circumscribed  bronchophony  or  pectoriloquy,  with  cavernous  dry 
or  moist  rales,  indicates  a  cavity.  This  may  be  dependent  on  tubercular 
ulceration,  a  gangrenous  abscess,  or  a  bronchial  dilatation.  The  first  is 
generally  at  the  apex,  and  the  last  two  about  the  centre  of  the  lung. 

8.  Total  absence  of  respiration  indicates  a  collection  of  fluid  or  of  air 
in  the  pleural  cavity.  In  the  former  case  there  is  diffused  dullness,  and 
in  the  latter  diffused  resonance  on  percussion. 

9.  Marked  permanent  dullness,  with  increased  vocal  resonance  and 
diminution  or  absence  of  respiration,  may  depend  on  a  chronic  plastic 
pleurisy,  a  thoracic  aneurism,  or  a  cancerous  tumor  of  the  lung. 


DISEASES    OF   THE    RESPIRATORY   APPARATUS.  1  U? 

TPIE  FORMS  OF  PHTHISIS. 

The  most  recent  writers,  both  in  the  United  Slates  and  Europe,  are 
agreed  in  recognizing  three  principal  varieties  of  phthisis.*  It  is  of 
import,  both  to  the  prognosis  and  therapeutics  of  the  case,  to  distinguish 
these  aspects  of  the  disease;  and  although  in  many  cases  the  typo  is  by 
no  means  prominently  defined,  in  the  majority  there  is  no  great  difficulty 
in  assigning  them  to  one  or  another  class.     The  three  forms  are: — 

1.  Catarrhal  or  inflammatory  phthisis:  "Desquamative  pneumonic 
phthisis."  (Buhl.)     Chronic  broncho-pneumonia. 

2.  Fibroid  phthisis.  Cirrhosis  of  the  lung.  Chronic  pneumonic 
phthisis.     Bronchial  phthisis.     Chronic  interstitial  pneumonia. 

3.  True  primary  tuberculosis.  Tubercular  phthisis.  Tubercular  pneu- 
monia (Da  Costa). 

On  the  clinical  recognition  of  these  three  varieties,  Dr.  Alfred  L. 
Loom  is  says : — 

If  a  case  of  phthisis  present  himself  for  examination,  and  it  is  found 
that  the  disease  began  with  the  ordinary  symptoms  of  a  cold,  and  that 
this  cold  periodically  improved  and  relapsed,  but  that  the  cough  never 
left  him,  but  became  more  pronounced  and  deepened  into  what  we 
usually  find  in  advanced  phthisis,  accompanied  with  emaciation  and  occa- 
sional haemoptysis,  we  are  in  a  position  to  say  that  the  patient  presents 
the  usual  characteristics  of  catarrhal  phthisis. 

If,  however,  he  gives  a  history  of  persistent  cough  for  many  years,  as 
is  found  in  chronic  bronchitis,  and  eventually  furnishes  the  rational 
history  of  advanced  phthisis,  with  the  presence  of  cavities  in  the  lung, 
we  may  consider  him  as  having  the  disease  of  the  fibrous  form,  in  which 
cavities  are  the  result  of  dilated  bronchi. 

Finally,  if  the  patient  says  that  an  early  symptom  was  emaciation,  with 
impaired  digestion,  accompanied  by  a  dry,  hacking  cough,  and  if,  more- 
over, there  was  a  steady  rise  in  the  temperature,  we  are  justified  in  sus- 
pecting the  presence  of  tubercular  phthisis. 

*  Dr.  A.  B.  Shepherd,  Medical  Press  and  Circular,  July,  1876  ;  A.  L.  Loomis,  New 
York  Medical  Journal,  February,  1877;  Roswell  Park,  Chicago  Medical  Journal, 
September,  1878;  Prof.  Bartholow,  Mediccd  News  and  Abstract,  etc. 


144 


DIFFERENTIAL    DIAGNOSIS. 


Temperature. 


Physical  Signs. 


THE  FORMS  OF  PHTHISIS  — CHRONIC  CATARRHAL  PNEUMONIA.  t 

Period  of    Invasion...        Precursory  catarrh,  sometimes  pneumonia, 

croup,  measles,  or  other  inflammatory  disease; 
cough  "deepens,"  proceeding  from  the  trachea 
to  the  alveoli  and  bronchioles,  indicated  by 
dark  yellow  streaks  in  the  sputum.  Fever 
and  wasting  not  marked  at  outset.  Haemop- 
tysis not  common  at  this  period. 

The  hectic  is  more  of  a  remittent  or  inter- 
mittent than  of  a  continued  type;  with  a  range 
of,  say,  1.1°  C  between  evening- and  morning 
temperature;  the  evening  elevation  being  a 
constant  feature. 

The  fever  may  present  all  possible  variations 
in  the  same  individual.  A  sudden  accession 
may  be  regarded  as  an  indication  of  some  fresh 
inflammatory  process;  e.  g.,  pleuritis,  pneu- 
monia. 

With  marked  evening  rise  of  temperature, 
the  rate  of  respiration  does  not  correspondingly 
accelerate ;  hardly  ever  more  than  six  or  eight 
breaths  per  minute. 

In  the  first  stage,  feeble,  harsh  or  puerile 
respiratory  sounds  are  heard,  with  all  the  signs 
of  catarrh  at  apices  and  elsewhere. 

Dullness  usually  marked;  when  its  area 
accords  with  the  other  signs  it  is  a  compara- 
tively favorable  feature. 

The  presence  of  lobular  infiltration  may,  in 
some  cases,  cause  a  hollow  or  tympanitic  note. 

"Cracked-pot"  resonance  over  a  cavity  with 
thin  walls. 

Fremitus  is  intensified  over  cavities  connect- 
ing with  bronchi  and  containing  air. 

Bronchial  respiration,  bronchophony,  and 
sonorous  rules  are  heard  after  extensive  indu- 
ration. 

Not  impaired  in  the  early  stage,  but  when 
cavities  form,  hectic  and  emaciation  set  in  and 
we  have  "pneumonic  phthisis." 

May  continue  for  years,  until  pneumonic 
phthisis  is  developed,  when  it  lasts  only  a  few 
months. 


G  ENERA L   NUTRITK  >N. . 


DISEASES    OP   THE    RE3PIRATORY   APPARATUS. 


1  1 3 


COMPARISON  OF  THE  FORMS  OF  PHTHISIS. 


TUBERCULAR. 


More  or  less  dyspnoea,  gradually 
increasing.  Cough,  worse  in  winter, 
sometimes  absent  in  summer.  Hae- 
moptysis frequent.  Pulse  slightly 
rapid,  perhaps  irregular.  Expecto- 
ration often  profuse,  mucous  or 
muco-purulent. 


Elevation  of  temperature  and 
other  febrile  symptoms  very  varia- 
ble, sometimes  wholly  absent  (Bris- 
towe).     No  special  type. 


Notable  dullness  on  percussion, 
resonance  sometimes  tympanitic. 
Respiration  bronchial,  or  broncho- 
vesicular.  Bronchophony  and  in- 
creased vocal  resonance.  The  af- 
fected side  becomes  contracted  either 
entirely  or  in  part. 

Bronchial  dilatation  (fusiform) 
gives  the  physical  sign  of  a  cavity. 

Not  incompatible  with  apparent 
good  health. 

Duration  indefinite. 


Commences  in  the  alveoli,  bron- 
chioles, or  connective  tissue.  Pallor, 
fever,  emaciation  and  night-sweats 
early.  Cough  hoarse  and  hard, 
voice  hoarse  or  inaudible,  distress- 
ing laryngitis.  The  sputa  retain 
the  crude  character  of  the  mucous 
sputa  of  acute  bronchitis.  Spleen 
somewhat  enlarged. 

The  hectic  is  of  a  continued  type ; 
temperature  always  above  normal, 
but  not  much  higher  in  the  evening 
than  in  the  morning ;  i.  e.,  the  re- 
missions not  well  marked;  more- 
over it  resists  treatment. 

Signs  not  well  marked,  not  suffi- 
ciently so  to  account  for  the  symp- 
toms. Solidification  not  extensive. 
Expansion  unequal. 


Cavities    form    after    softening, 
with  destruction  of  lung  tissue. 

Health  obviously  impaired. 


Lasts  about  a  year. 


THE  DIAGNOSIS  OF  INCIPIENT  PHTHISIS. 

There  is  no  absolutely  sure  symptom  of  phthisis  previous  to  percussion 
dullness,  but  a  very  strong  presumption  of  its  approach  can  be  drawn 
from  the  presence  of  the  following  changes  : — 

1.  Emaciation.  Where  there  is  progressive  emaciation  without  assign- 
able cause,  and  especially  if  the  appetite  continue  good,  phthisis  should 
always  be  suspected.  The  loss  of  flesh  first  shows  itself  in  a  retraction 
of  the   skin  over  the  cheeks,  a  thinning  of  the  lips  and  ears,  and  a 


146  DIFFERENTIAL   DIAGNOSIS. 

pinched  appearance  of  the  nose.     The  nostril  on  the  affected  side  is  usu- 
ally slightly  more  dilated  than  the  other. 

2.  Ancemia,  seen  in  the  bluish  hue  of  the  sclerotic,  and  in  the  pallor 
of  the  cheeks. 

3.  Sore  throat  and  hoarseness.  A  very  early  symptom.  On  exami- 
nation the  pillars  of  the  fauces  are  found  hyperamiic,  the  throat  con- 
gested and  the  bronchial  glands  enlarged. 

4.  Sitrlling  of  mucous  membrane  of  larynx,  especially  forming  a  tur- 
ban-shaped epiglottis,  which  at  the  same  time  assumes  a  horse-shoe  bend; 
and  pyriform  enlargement  over  the  arytenoid  cartilages  (Seiler).* 

5.  Depression  of  the  acromial  end  of  the  clavicle,  on  the  affected  side. 
In  health  the  acromial  end  is  slightly  higher  than  the  sternal  end. 

6.  Rheumatoid  pains  in  the  arms  coming  suddenly  at  night  or  in  the 
early  morning,  not  increased  on  moving  the  arms. 

7.  Pityriasis  versicolor,  in  the  form  of  pale  yellow  or  reddish  spots 
appearing  on  the  skin  of  the  chest,  neck  and  arms.  This  is  considered 
by  Aufrecht  a  very  characteristic  symptom. 

8.  In  regard  to  the  breathing,  what  is  considered  as  suspicious  are 
weak,  jerking,  "  cogged  wheel  "  or  sonorous  sounds,  rough  breathing,  a 
lengthened  strong  expiration  after  soft  inspiration,  especially  when  in  cir- 
cumscribed regions  these  sounds  differ  from  those  on  the  other  side  of 
the  chest.  The  most  appropriate  spot  to  note  the  duration  of  expiration 
is  over  the  larynx  or  trachea.  In  proportion  as  the  tubercular  deposit  is 
more  extended,  the  expiratory  murmur  becomes  more  tubercular  in  qual- 
ity and  higher  in  pitch  (Armor).  In  normal  cases  the  respiratory 
sound  becomes  weaker  in  the  supra-spinous  region  outward  from  the 
vertical  column.  Dr.  Heitler  considers  it,  therefore,  strong  evidence  of 
incipient  pulmonary  phthisis  if  the  respiratory  sounds  during  expiration 
are  more  sonorous  over  these  regions  than  nearer  to  the  vertebral  col- 
umn.f 

9.    Unequal  expansion  of  chest  is  an  early  sign  of  commencing  disease 
of  the  apex.     The  expansion  is  less  on  the  diseased  side. 

10.  Alterations  in  temperature  curve  frequently  take  place  early.  The 
temperature  may  be  low,  but  its  characteristic  range  will  be :    (1)  a 

*  Proceedings  Philadelphia  Co.  Medical  Society,  vol.  ii,  p.  101,  Philada.,  1880. 
f  Dobell's  Reports  on  Diseases  of  the  Chest,  1877. 


DISEASES    OF  THE    RESPIRATORY   APPARATUS.  1  17 

marked  rise  after  2  p.m.;  (2)  a  rapid  fall  after  10  p.m.;  (3)  minimum 
about  7  a.m.;  (4)  recovery  to  normal  about  10  a.m.  (C.  T.  Williams). 
Such  a  curve  must  always  excite  grave  suspicions. 

11.  Rapidity  of  pulse.  A  persistent  and  sustained  increase  in  the  pulse 
rate,  without  cardiac  disease,  is  a  valuable  rational  sign,  present  very 
early  in  most  cases. 

12.  The  cough  of  incipient  phthisis  is  usually  short,  hacking,  and  dry, 
or  with  a  slight,  glairy,  mucous  expectoration  only.  From  the  presence 
of  fragments  of  the  pulmonary  fibrous  tissue  in  the  sputum,  "we  are 
sometimes  enabled  to  suspect  the  existence  of  consumption  before  the 
physical  signs  of  even  its  early  stages  are  well  defined."  (Da  Costa.)* 

13.  Haemoptysis.  The  appearance  of  haemoptysis  is  always  a  serious 
element  of  diagnosis.  Light,  frothy,  red  blood,  rising  without  apparent 
exertion,  is  an  indication  which,  in  America  at  least,  has  proved  of  graver 
meaning  the  more  it  has  been  investigated.f  On  the  other  hand,  cases 
will  be  met  with  sometimes,  in  whom  there  may  be  considerable  haemop- 
tysis, with  marked  dullness  at  the  apex,  without  the  significance  of 
tubercle.J 

14.  Clubbing  of  the  finger  ends,  when  associated  with  incurvation  of 
the  sides  and  tips  of  the  nails,  means  obstruction  of  the  subclavian  veins, 
which  is  one  of  the  earliest  effects  of  tuberculosis ;  but  clubbing  without 
this  incurvation  is  rather  against  the  probability  of  tubercle  (Dobell). 

15.  Amennorrhea  is,  in  young  females,  often  one  of  the  earliest  signs  of 
phthisis. 

16.  A  red  line  is  occasionally  noticed  on  the  gums  at  the  base  of  the 
teeth. 

17.  Arthritis.  M.  Laveran§  has  drawn  attention  to  the  occasional 
occurrence  of  arthritis  as  the  first  symptom  of  a  general  tuberculosis. 

*  To  examine  sputa  for  elastic  fibres,  mix  it  with  a  soda  solution  : — 
R .     Liquor  soda?,  1  part 

Aquas  destill.,  2  parts.  M. 

And  boil  for  four  or  five  minutes.  Then  dilute  with  an  equal  quantity  of  distilled 
water,  and  pour  into  a  flat  porcelain  vessel.  The  particles  suspended  in  the  water  may 
then  be  taken  out  and  examined  under  the  microscope.  The  fibres  in  this  process  are 
brown,  slightly  reticulated,  and  a  fraction  of  a  millimetre  in  length  (Sokoi.owski). 

f  See  second  Report  of  the  New  York  Mutual  Life  Insurance  Company,  1877. 

%  See  Prof.  Da  Costa,  in  Medical  and  Surgical  Reporter,  July  13,  1878. 

I  Le  Progres  Medical,  October  25,  1876.     Quoted  by  Dr.  M.  Axderson. 


148 


IWI'IF.KKNTIAI.    DIAGNOSIS. 


DIAGNOSIS  BETWEEN  INCIPIENT   PHTHISIS  AND 
BRONCHITIS. 


INCIPIENT  PHTHISIS. 

1.  The  cough  commences  gradu- 
ally, without  marked  disturbance  or 
coryza,  often  preceded  by  slight  loss 
of  flesh  and  strength. 

2.  The  cough  is  generally  dry  and 
hacking  at  commencement,  followed 
by  the  expectoration  of  a  thin  mu- 
cous fluid,  which  soon  becomes  thick 
and  opaque,  or  is  slightly  streaked 
with  blood. 

3.  Examination  by  the  micro- 
scope shows  portions  of  lung  tissue 
(yellow  elastic  fibres)  in  the  sputa. 

4.  Pain  of  a  wandering  character 
about  the  chest,  especially  under  the 
clavicles  or  between  the  shoulders. 

5.  Evening  rise  of  temperature. 

6.  The  morbid  physical  signs  usu- 
ally confined  to  upper  lobe  of  one 
side;  are  very  persistent,  and  if  on 
both  sides  at  first,  apt  to  subside  on 
one  and  increase  on  the  other. 

7.  Family  history  and  general 
appearance  indicate  tuberculous  ca- 
chexia.    Most  frequent  in  youth. 

8.  Essentially  chronic. 

While  these  points  of  difference  between  tubercular  disease  and  catar- 
rhal inflammation  of  the  mucous  membrane  lining  the  bronchial  tubes 
are  in  the  main  reliable,  yet  it  must  not  be  forgotten  that  chronic  bron- 
chitis is  often  attended  by  structural  changes  in  the  lung,  leading  in  one 
set  of  cases  to  increase  of  connective  tissue,  with  dilated  bronchiae-fibroid 
degeneration,  chronic  broncho-pneumonia — and  in  another  to  deposits, 
chiefly  epithelial,  in  the  air  cells,  producing  spots  of  consolidation. 


BRONCHITIS. 

1.  The  cough  commences  sud- 
denly, and  is  usually  ushered  in  by 

|  feverishhess  and  coryza. 

2.  The  cough  is  accompanied 
with  expectoration  almost  from  the 
first;  generally  abundant;  frothy  or 
muco-purulent;  not  often  blood- 
stained. 

3.  No  evidence  of  destruction  of 
lung  tissue. 

4.  A  feeling  of  tightness  and  raw- 
ness behind  the  sternum,  aggravated 
by  coughing. 

5.  Elevation  of  temperature  not 
particularly  marked  toward  evening. 

6.  Morbid  signs  usually  predomi- 
nate in  the  lower  lobes;  are  on  both 
sides;  are  of  temporary  duration, 
and  subside  gradually  and  equally 
on  both  sides. 

7.  No  marked  hereditary  tend- 
ency; common  at  all  ages. 

8.  Has  an  acute  beginning. 


DISEASES   OF   THE   RESPIRATORY   APPARATUS. 


I  I 'J 


The  general  clinical  history  of  phthisis  may  he  summed  up  in  the  fol- 
lowing brief  table : — 

PULMONARY  PHTHISIS.    (CHRONIC  TUBERCULAR  PNEUMONIA.) 


STAGE  OF 
DISEASE. 


1st  stage 

(incipient). 
Stage  of 
invasion. 


2d  stage 


(confirmed), 
stage  of 
deposit. 


3d  stage 
(advanced). 

Stage  of  soft- 
ening and 
formation  of 
cavities. 


Cough  at  first  dry,  then 
with  expectoration  of  mu- 
cus, frequently  streaked  or 
dotted  with  blood,  or  with 
copious  haemoptysis.  Dys- 
pnoea. Pains  in  the  various 
parts  of  the  chest,  especi- 
ally on  the  affected  side. 
Dislike  to  fatty  articles, 
and  other  dyspeptic  symp- 
toms; tendency  to  vomit- 
ing after  paroxysms  of 
coughing;.  Night-sweats. 
Emaciation.  In  females, 
disturbance  of  the  catame- 
nial  functions.  Occasion- 
ally hectic. 

Cough  more  severe,  with 
puriform  expectoration,  of 
a  yellow  or  greenish  hue, 
and  often  bloody.  Pro- 
fuse night-sweats  and  rap- 
idly progressive  emaciation. 
Pinched  and  anxious  ex- 
pression. Loss  of  appe- 
tite. Thirst.  Diarrhoea. 
Sometimes  hectic. 

Cough  rather  looser,  still 
with  puriform  (nummular) 
expectoration,  or  attacks  of 
copious  haemoptysis.  Ex- 
treme emaciation  and  debil- 
ity, with  or  without  night- 
sweats.  Voice  husky  and 
hollow.  Aphthae  on  mouth 
and  fauces.  Hectic.  Clubbed 
fingers  and  talon-like  nails. 


PHYSICAL   SIGN'S. 


Diminished  movements.  In- 
creased vocal  fremitus.  Loss 
of  percussion  resonance, 
rise  in  pitch,  or  a  boxy, 
wooden  note  beneath  the 
clavicle  or  in  the  interscap- 
ular region.  Feeble,  coarse, 
or  interrupted  vesicular 
murmur,  with  prolonged  ex- 
piration. Increased  vocal  re- 
sonance. Occasional  sibilus 
or  creaking  friction  sound. 
Heart  sounds  abnormally 
loud  over  affected  side. 
Subclavian  murmur.  Pue- 
rile (exaggerated)  respira- 
tion on  sound  side. 

Greater  diminution  of  move- 
ment of  the  affected  side, 
and  some  amount  of  flat- 
tening. Increased  vocal 
fremitus.  Increased  dull- 
ness, extending  downward. 
Bronchial  breathing,  mixed 
with  mucous  rales  or  with 
click  at  the  end  of  each  in- 
spiration.     Bronchophony. 

Scarcely  any  movement  of 
the  affected  side.  Marked 
flattening.  Increased  vocal 
fremitus.  Dullness  less 
marked.  Box-like  reso- 
nance or  cracked-pot  sound. 
Cavernous  breathing,  with 
gurgling  and  splash  on 
cough.  Occasionally  metal- 
lic sounds.     Pectoriloquy. 


150  DIFFERENTIAL  DIAGNOSIS. 

PHTHISIS— (Continued ). 

COMPLICATIONS  NOT  RESTRICTED  TO  ANY  PARTICULAR  STAGE 
OF  PHTHISIS. 

The  chief  of  these  are:  Affections  of  the  larynx  and  trachea,  especially 
ulceration ;  bronchitis,  intercurrent  pneumonia,  or  pleurisy ;  perforation 
of  the  pleura,  with  pneumo-hydrothorax  or  empyema;  enlargement  of 
the  external  absorbent  glands,  or  of  those  in  the  chest  and  abdomen ; 
tubercular  peritonitis;  ulceration  of  the  intestines,  especially  the  ileum; 
fatty  or  amyloid  liver;  fistula  in  ano;  various  forms  of  Bright's  disease; 
diabetes;  pyelitis;  tubercular  meningitis,  or  tubercle  in  the  brain,  and 
thrombosis  of  the  veins  of  the  legs. 

POST-MORTEM  APPEARANCES. 

First  stage.  Usually  most  marked  at,  or  even  confined  to,  one  apex, 
Avhere  are  to  be  seen  gray,  semi-transparent  nodules,  varying  in  size  from 
a  small  pin's  head  to  a  hemp-seed ;  the  lung-tissue  around  these  nodules 
may  be  healthy,  but  is  generally  hypersemic  and  congested,  slightly  in- 
creased in  density.  In  more  advanced  cases,  in  addition  to  the  miliary 
nodules,  there  may  be  small  yellow  masses,  less  defined,  but  larger  than 
the  gray  variety.  Both  kinds  may  either  be  scattered  or  several  in  one 
group,  forming  a  considerable  mass. 

Second  stage.  Commencement  of  caseation  and  softening  in  the  cen- 
tre of  the  consolidated  portions,  inflammation  of  the  surrounding  paren- 
chyma, together  with  obliteration  of  the  blood-vessels  and  formation  of 
cicatricial  tissue. 

TJtird  stage.  Cavities  of  various  sizes  and  forms,  and  either  single  or 
numerous,  generally  containing  puriform  fluid.  Ulceration  and  dilation 
of  the  bronchial  tubes.  Lung  indurated  and  puckered  in  proportion  to 
chronicity  of  disease. 

ACUTE  PHTHSIS,  ACUTE  MILIARY  TUBERCULOSIS, 
GALLOPINQ  CONSUMPTION. 

The  formidable  disease  known  under  these  names  is  probably,  as  M. 
Bouchut  remarks,  more  common  than  is  generally  supposed,  as  it  is  gen- 
erally mistaken  either  for  capillary  bronchitis  or  typhoid  fever,  especi- 
ally the  latter.  Its  duration  is  brief,  sometimes  less  than  a  fortnight 
(Da  Costa),  and  its  termination  almost  invariably  fatal.     Its  features 


DISEASES   OF  THE    RESPIRATORY   APPARATUS.  151 

are  thus  so  entirely  distinct  from  the  chronic  form,  from  the  clinical 
point  of  view,  as  to  really  constitute  it  a  separate  disease. 

Its  onset  is  marked  by  chills  and  feverishness,  nausea,  vomiting  and 
diarrhoea.  There  is  a  rapid  pulse;  dyspnoea;  slight  pain  in  the  chest; 
cough,  usually  with  profuse  expectoration.  Great  exhaustion,  sweats, 
rapid  emaciation,  and  delirium,  soon  follow.  One  or  both  lungs  exhibit 
unusual  dullness,  while  the  auscultatory  sounds  differ  greatly  in  different 
cases. 

The  following  are  the  marked  diagnostic  features  of  the  disease  : — 

1.  Facial  expression.  The  countenance  is  livid,  indicating  plainly  an 
impediment  to  the  passage  of  blood  through  the  lungs.  In  severe  typhoid 
fever  the  cheeks  are  slightly  flushed,  the  facial  muscles  tremulous,  the 
eyes  dull,  and  the  mouth  partly  opened,  presenting  an  appearance  charac- 
teristic of  the  disease.* 

2.  The  delirium  of  acute  phthisis  is  restless  and  often  violent,  but  the 
rambling  and  wild  talk  is  connected  usually  with  things  present  or  near. 
In  typhoid  fever  the  delirium  is  generally  muttering  and  low;  the  mind 
deals  with  things  absent,  and  the  patient  "is  like  a  man  talking  in  his 
dreams"  (Watson). 

3.  The  tongue  in  acute  phthisis,  at  first  covered  with  a  white  fur,  soon 
becomes  red,  glassy  and  dry.  In  typhoid  it  usually  changes  to  a 
brownish  hue. 

4.  The  ophthalmoscope  is  a  most  positive  aid  to  the  diagnosis,  accord- 
ing to  M.  Bouchut.  In  all  cases  of  acute,  general,  miliary  tuberculosis, 
an  ophthalmoscopic  examination  will  reveal  the  presence  of  tubercular 
granulations  in  the  choroid,f  thus  placing  the  nature  of  the  disease  be- 
yond doubt. 

5.  Abdominal  symptoms.  Diarrhoea  and  gastric  and  abdominal  pains  are 
often  present  in  acute  phthisis ;  but  the  red  spots  of  typhoid  are  not  seen. 

6.  Chest  symptoms.  Dyspnoea  is  present  always,  but  the  orthopncea  of 
capillary  bronchitis  is  rare  (Shaw).  The  respiration  is  greatly  cmickened, 
and  the  proportion  to  the  pulse  averages  1 :  3  (Walshe).  The  presence 
of  percussion  dullness,  a  sinking  in  at  the  upper  part  of  the  chest,  and  the 
occurrence  of  hemorrhage,  are  conclusive  evidence  of  tubercle  (Da  Costa). 

*  L.  J.  "Woollen,  American  Practitioner,  July,  1871. 
t  Medical  Times  and  Gazette.    January,  1875. 


152  DIFFERENTIAL   DIAGNOSIS. 

7.  The  sputum  shows  the  characteristic  serous  and  rauco-purulent 
character,  and  may  contain  the  elastic  fibre  of  lung  tissue. 

DIAGNOSIS  OF  SYPHILITIC  PHTHISIS. 

The  distinctive  traits  of  this  form  of  consumption  have  lately  been 
separately  studied  by  Dr.  MacSwinney,  of  Dublin,and  Dr.  Pentimalli, 
of  Naples.     Their  results  are  combined  in  the  following  scheme: — 

1.  Absence  of  hereditary  tendency,  of  a  phthisical  habitus,  and  of  pre- 
ceding pulmonary  affections. 

2.  History  of  syphilitic  disease  in  other  organs,  and  presence  of  the 
syphilitic  cachexia  in  its  tertiary  stage. 

3.  The  disease  never  begins  in  the  apex,  and  is  limited  in  its  seat, 
being  unilateral  and  generally  posterior  (Pentimalli). 

4.  Haemoptysis  rare,  febrile  symptoms  absent  or  slight. 

5.  Slowness  in  development,  the  acuter  phthisical  symptoms  not 
manifest. 

6.  Exacerbation  of  pain  during  the  night. 

7.  A  peculiarly  fetid  breath. 

8.  Reference  of  the  feeling  of  oppression  to  the  larynx  rather  than  to 
the  chest. 

9.  Failure  of  ordinary  measures,  and  improvement  under  specific  medi- 
cation. 

BRONCHITIS,  ACUTE  AND  CHRONIC. 

In  most  cases  of  bronchitis  the  inflammation  is  seated  in  the  larger 
bronchial  tubes.  There  is  more  or  less  swelling  of  their  lining  mucous 
membrane,  not  generally  sufficient  to  prevent  a  free  passage  to  the  breath- 
ing air.  The  characters  of  the  acute  and  chronic  form  are  set  forth  in 
the  tables,  in  the  following  pages. 

There  is  a  variety  of  chronic  bronchitis,  in  which  the  material  exuded 
on  the  surface  of  the  air  passages  contains  a  large  proportion  of  a 
fibrinous  constituent  which  makes  it  tough  and  consistent,  so  that  when 
expelled  the  substance  appears  as  a  perfect  cast  of  the  bronchial  tube  in 
which  it  was  formed.  This  is  called  fibrinous  bronchitis,  and  does  not 
differ  in  pathology  from  the  ordinary  chronic  variety,  but  is  less  sus- 
ceptible to  treatment.  Its  diagnosis  is  made  from  the  appearance  of  the 
casts,  and  needs  no  further  mention  here. 


DISEASES   OP  THE   RESPIRATORY   APPARATUS. 


L5 


ACUTE  BRONCHITIS. 


1st     or     Dry 

Stage. 


2d   or    Moist 
Stage. 


3d  Stage. 
(Termina- 
tion  favor- 
able.) 

Unfavorable. 


Chilliness,  followed  by  fre- 
quent pulse  and  febrile 
symptoms ;  pains  in  limbs. 
Substernal  pain.  Hoarse 
dry  cough.  Feeling  of 
oppression  and  tightness 
about  the  chest. 


Cough,  with  expectoration 
of  frothy,  transparent 
mucus,  mixed  with  air- 
bubbles  of  various  sizes, 
and  occasionally  tinged 
or  streaked  with  blood. 
Urgent  dyspncea,  often 
amounting  to  orthopncea. 
Lividity  and  febrile 
symptoms  increased. 
Restlessness  at  night. 

Gradual  remission  of  the 
symptoms.  Expectora- 
tion becomes  thick,  green- 
ish, and  opaque,  and 
sometimes  nummulated. 

Dyspnoea  very  urgent,  signs 
of  impending  suffocation. 
Profuse  cold  sweats.  Sink- 
drowsiness  and  de- 
Less  cough,  ab- 
sence of  expectoration. 


lirium. 


I'UYHICAI,   ,sh;xs. 


Breathing  hurried.  Rhon- 
chal  fremitus  may  be  felt. 
Resonance  on  percussion 
unimpaired.  Feeble  vesi- 
cular murmur,  mixed 
with  rhonchus  and  sibilus. 
Puerile  breathing  in  un- 
obstructed parts  of  lung. 
Vocal  resonance  not  ma- 
terially altered. 

Breathing  hurried.  Rhonchal 
fremitus  may  be  felt.  Re- 
sonance on  percussion 
clear  or  only  very  slightly 
impaired.  Feeble  vesicu- 
lar murmur  mixed  with 
rhonchus,  sibilus  and  mu- 
cous rales.  Vocal  reson« 
ance  unaltered. 


Less  amount  of  sonoro-sibil- 
ant  and  mucous  rales,  with 
return  of  normal  vesicular 
breathing. 

In  addition  to  the  signs  of 
the  second  stage,  tracheal 
rales  may  be  heard. 


The  -post-mortem  appearances  are  :  Congestion  of  mucous  membrane  of 
bronchial  tubes,  with  some  degree  of  swelling  and  dryness  of  surface. 

Lungs  do  not  collapse  when  the  chest  is  opened ;  nor  do  sections  sink 
in  water.  The  mucous  membrane  of  the  bronchi  is  red  and  swollen,  and 
the  tubes  filled  with  frothy,  adhesive  mucus. 


154 


DIFFERENTIAL    DIAGNOSIS. 


CHRONIC  BRONCHITIS. 


PHYSICAL    SIGN'S. 


Respiration  labored  and  abdom- 
inal. Vocal  fremitus  not  materially 
altered ;  rhonehal  fremitus  can  gener- 
ally be  felt.  Impairment  of  reson- 
ance or  a  hyper-resonant  note,  ac- 
cording as  collapse  of  lung  and  con- 
solidation, or  emphysema  predomin- 
ate, the  former  most  marked  at  the 
bases,  the  latter  at  the  anterior  part. 
Feeble  vesicular  murmur.  Rhou- 
chus,  sibilus,  and  mucous  rales.  Vo- 
cal resonance  varies. 


Two  chief  forms :  the  one 
characterized  by  the  sputa  being 
expectorated  with  great  difficulty, 
consisting  of  small,  gray,  semi-trans- 
parent pellets,  and  tending  toward 
emphysema;  in  the  other  the  sputa 
are  abundant,  muco-purulent,  and 
brought  up  with  ease;  dilatation  of 
the  bronchi  frequently  associated 
with  this  form.  The  cough  gener- 
ally comes  on  at  the  approach  of 
winter  ;  with  the  history  of  former 
attacks.  Dyspnoea;  lividity  of  sur- 
face ;  and  in  some  cases  the  symp- 
toms resemble  those  of  chronic 
phthisis,  as  wasting,  with  night 
sweats  and  hectic. 

The  post-mortem  appearances  are : — 

Lungs  generally  much  congested,  presenting  a  dark  livid  hue,  with 
portions  collapsed,  and  others  emphysematous.  Bronchial  tubes  fre- 
quently dilated.  Mucous  membrane  thickened,  uneven,  sometimes  ulcer- 
ated, covered  by  a  thick,  puriform  secretion,  or  sparingly  coated  by  a 
tenacious,  glairy,  semi-transparent  substance. 

The  principal  diseases  with  which  bronchitis  may  be  confounded  are 
pneumonia,  pleurisy  and  phthisis.  But  each  of  these  is  characterized  by 
the  presence  of  definite  physical  signs,  which  are  not  to  be  found  in 
ordinary  bronchitis.  For  instance,  in  this  disease  there  is  no  disparity 
between  the  two  sides  of  the  chest  in  the  resonance  obtained  by  percus- 
sion, nor  in  vocal  resonance,  the  bronchial  whisper  and  fremitus.  The 
swelling  of  the  bronchial  mucous  membrane  may  cau->e  some  diminution 
of  the  intensity  of  the  vesicular  murmur  ;  but  as  the  affection  is  bilateral 
and  the  bronchial  tubes  on  both  sides  are  affected  equally,  both  in  degree 
and  extent,  there  is  no  appreciable  disparity  between  the  two  sides. 
Sometimes  temporary  weakening  or  suppression  of  the  murmur  may  be 
caused  by  a  plug  of  mucus,  which  will  be  detected  on  a  second  examina- 
tion (Flint),  or  by  instructing  the  patient  to  cough,  so  as  to  dislodge  it. 


DISEASES    OF   THE    RESPIRATORY   APPARATUS. 


155 


CAPILLARY  BRONCHITIS. 

Acute  capillary  bronchitis  may,  however,  be  taken  for  some  of  the 
forms  of  pneumonia,  and  in  fact  the  descriptions  of  some  writers  would 
lead  to  the  belief  that  they  have  committed  this  error.  The  following 
distinctions  will  make  the  diagnosis  easy  in  most  cases : — 

PNEUMONIA. 


CAPILLARY  BRONCHITIS. 

Commences  in  the  external  air 
passages  as  a  common  cold  and  ex- 
tends downward. 

Always  bilateral. 

Normal  or  exaggerated  resonance 
on  percussion  unless  collapse  has 
commenced. 

Sub-crepitant  rales  on  both  sides 
of  the  chest. 

Respiration  not  bronchial,  50  or 
more;  pulse  150  or  more. 

Muco-purulent  expectoration ;  no 
plastic  lymph. 

Dyspnoea  intense ;  cyanosis  early. 
No  pain  or  but  little. 

Death  from  asphyxia;  mortality 
more  than  half. 

A  disease  of  children. 


Commences  suddenly  with  a  chill, 
and  attacks  the  lungs  directly. 

Generally  unilateral. 
Dullness  on  percussion  more  or 
less  extensive  at  the  outset. 

Crepitant  rale. 

Respiration  bronchial,  25  to  40 
per  minute.     Pulse  100  to  130. 

Rust-colored  expectoration ;  plas- 
tic lymph  in  pulmonary  air  cells. 

Dyspnoea  less ;  cyanosis  late  if  at 
all.     Pain  in  the  side. 

Death  from  asthenia;  mortality 
ten  per  cent. 

A  disease  of  adult  life. 


PNEUMONIA  AND  PLEURISY. 

Ordinary  acute  inflammation  of  the  lungs  in  its  early  or  first  stage  is 
well  marked  by  the  presence  of  a  moderate  or  slight  dullness  on  percus- 
sion over  the  affected  lobe,  and  the  detection  on  auscultation  of  the 
crepitant  rale.  The  latter  is  indeed  not  invariably  present,  but  wrhen  it 
is,  taken  in  connection  with  the  symptoms,  it  is  pathognomonic. 

Later  in  the  disease  the  rust-colored  expectoration  of  pneumonia  on 
the  one  hand,  and  the  physical  signs  of  effused  liquid  into  the  pleural 
cavity  in  pleurisy  on  the  other  hand,  offer  distinctive  features. 

The  general  clinical  histories  of  the  diseases  are  given  in  the  following 
tables : — 


156 


DIFFERENTIAL    DIAGNOSIS. 


PNEUMONIA. 


1st  Stage. 

(Engorge- 
ment.) 


2d  Stage. 
(Red 
hepatization.) 


3d  Stage. 
a  (Gray 
hepatization.) 


or 


b  (Resolu- 
tion.) 


SYMPTOMS. 


Single,  severe  rigor  (or  convul- 
sions in  children),  followed  by 
heat  of  skin.  Increased  fre- 
quency of  pulse.  Respiration 
greatly  accelerated,  with  con- 
sequent disturbance  of  the 
pulse-respiration  ratio.  Dysp- 
noea. Pain  in  the  side,  in- 
creased by  cough  or  deep  in- 
spiration. Cough,  at  first  dry, 
with  rusty  sputa  about  the 
second  or  third  day.  Inability 
to  lie  on  affected  side.  Dilated 
alee  nasi.     Herpes  about  lips. 

Increased  distress  and  dysp- 
noea. Respiration  and  speech 
panting.  Cough  more  urgent, 
and  sputa  still  rust-colored, 
extremely  viscid,  and  tena- 
cious. Absence  or  deficiency 
of  chlorides  in  the  urine. 


Aspect  much  distressed.  Face 
pale  and  livid.  Great  failure 
of  vital  powers.  Hectic  and 
delirium.  Cough  continues, 
and  the  sputa  are  either  absent, 
or  sometimes  they  remain  rust- 
colored  ;  at  others  become 
like  prune-juice,  even  fetid. 

Symptoms  yielding  about  7th 
day  of  disease.  Cough  less 
troublesome,  expectoration 
easier.  Patient  evidently  con- 
valescing. 


l'll\  SICA1.  SHINS. 


Diminished  movement 
on  the  affected  side. 
Respiration  abdominal. 
Vocal  fremitus  normal. 
Percussion  note  not  ma- 
terially affected.  Feeble 
vesicular  breathing. 
Fine  crepitant  rale,  most 
frequently  heard  at  base 
of  lung  and  at  the  end 
of  inspiration. 


Very  slight  movement. 
Vocal  vibrations  well 
marked.  Dullness  on 
percussion.  Tubular 
breathing  and  broncho- 
phony, generally  accom- 
panied by  some  rales,  if 
at  the  commencement 
of  the  2d  stage  of  a 
crepitant  character,  and 
afterward  of  a  mucons 
nature. 

Absol  ute  dullness  on 
percussion .  Tubular 
breathing  and  broncho- 
phony, frequently  with 
gurgling  rales  where  the 
lung  is  disorganized. 


Dullness  diminishing  by 
absorption.  Broncho- 
vesicular  breathing  with 
crepitant  redux  rales 
yielding  to  normal  vesi- 
cular murmur,  and  per- 
cussion-note. 


DISEASES    OF  THE    RESPIRATORY   APPARATUS. 


157 


Post-mortem  Appearances. — Lungs:  1st  stage.  Engorged  with 
frothy  and  bloody  serum.  Dark-red  eolor  externally,  and  on  section. 
Crepitating  less,  and  heavier,  than  sound  lung,  but  still  floating  in  water. 
Pulmonary  tissue  slightly  softened. 

2d.  Red  externally,  red  or  mottled  and  granular  on  cut  surface,  and  of 
liver-like  solidity.  Easily  torn,  and  with  fluid  exuding  on  pressure  less 
abundant  than  in  first  stage,  but  thicker,  and  towards  the  end  of  this 
stage  becoming  purulent.     Not  crepitating,  and  sinking  in  water. 

3d.  Reddish-yellow  or  gray.  More  rotten  and  friable.  Purulent  fluid 
exudes  from  the  cut  surface;  and,  on  pressure,  the  whole  lung  may  be 
reduced  to  a  pulp-like  mass. 

PLEURISY. 

The  symptoms  of  pleurisy  are  attributed  to  inflammation  of  the  serous 
covering  of  the  lungs,  and  is  to  be  distinguished  from  passive  effusion 
into  the  pleural  sac,  which  is  known  as  hydrothorax,  which  is  readily 
recognized  by  the  following  points  of  difference  : — 


PLEURISY. 

Due  to  inflammation  (active). 
'  Has  an  acute  beginning,  accom- 
panied by  stitch  in  the  side,  cough, 
constitutional  disturbance,  pyrexia, 
etc. 

May  be  traced  to  traumatic 
causes,  or  to  exposure  to  wet  and 
cold;  or  may  complicate  zymotic 
diseases. 

One  side  only  affected,  as  a  rule. 

Runs  its  course  in  a  few  days,  ter- 
minating in  chronic  pleuritic  effu- 
sion, or  in  absorption  of  fluid. 

No  complications  generally. 


HYDROTHORAX. 

Due  to  transudation  (passive). 

Effusion  takes  place  insidiously, 
without  local  or  general  symptoms, 
beyond  those  caused  mechanically 
by  pressure  on  the  thoracic  viscera. 

Due  to  blood  disorder,  accom- 
panying renal  disease,  or  more  rarely 
to  obstruction  to  circulation  by 
morbid  growths,  or  valvular  disease 
of  heart. 

May  be  bilateral. 

Remains  stationary  for  months, 
or  may  slowly  increase. 

Accompanied  by  albuminuria, 
heart  disease,  and  dropsy  elsewhere 
in  the  body. 


158 


DIFFERENTIAL   DIAGNOSIS. 


PLEURISY. 


Pleurisy  : 

1st  Stage,  or 
Stage  of  Hy- 
peremia. 


2d  Stage,  or 
Stage  of  Ef- 
fusion. 


Rigors,  or  more  fre- 
quently mere  chilliness. 
Sharp,  stabbing  pain  in 
the  side,  increased  by 
deep  inspiration  or 
cough,  accompanied 
by  more  or  less  ten- 
derness on  pressure. 
Breathing  short  and 
hurried.  Respiration 
chiefly  abdominal,  with 
inability  to  lie  on  the 
affected  side.  Short, 
dry  cough,  or  none  at 
all.  Pulse  full  and 
bounding.  Febrile 
symptoms. 

Cough,  dyspnoea,  sense 
of  weight  and  fullness 
of  the  affected  side.  Fe- 
brile symptoms  less 
marked.  Patient  lies 
toward,  not  on,  the  af- 
fected side.  Complex- 
ion inclined  to  be  dusky. 


PHYSICAL    SKiXS. 


Diminished  movement  on  the  af- 
fected side.  Friction  fremitus 
may  sometimes  be  felt.  Percus- 
sion sound  not  materially  alter- 
ed. Vesicular  murmur  feeble 
and  jerking  in  rhythm.  To- 
and-fro-friction  sound. 


Almost  total  absence  of  move- 
ment of  the  affected  side,  which 
is  unduly  prominent,  the  inter- 
costal spaces  being  obliterated 
or  even  bulging.  Integuments 
occasionally  oedematous.  Vocal 
vibrations  absent.  Complete 
dullness  on  percussion,  most 
marked  in  the  dependent  por- 
tions of  the  chest,  and  some- 
times altered  by  change  of  pos- 
ture. Heart  pushed  over  to 
sound  side,  and  diaphragm 
pushed  down,  so  that  the  liver 
and  stomach  descend  lower  into 
the  abdomen  than  in  health. 
Vesicular  murmur  almost,  or 
quite,  absent.  Frequently  bron- 
chial breathing  near  the  spine. 
Voice  sounds  absent  or  feeble, 
except  when  the  layer  of  fluid 
is  thin,  and  then  there  may  be 
segophony.  No  friction  sound. 
Puerile  breathing  in  sound  1  ung. 


DISEASES    OF   TIIE    RESPIRATORY   APPARATUS. 


1 59 


PLEURISY— ( Continued ) . 


3d  Stage  (Res- 
olution after 
Effusion). 


SYMPTOMS. 


Gradual  diminution  of 
the  cough,  dyspnoea, 
and  other  symptoms. 
Returning  ability  of  the 
patient  to  lie  on  the 
sound  side.  Gradual 
return  of  displaced  or- 
gans to  their  normal 
position. 


IMIYSIOAI,  SIGNS. 


The  movement  of  the  chest  grad- 
ually increases.  Return  of  vocal 
vibration  and  friction  fremitus. 
The  dullness  on  percussion  di- 
minishes from  above  down- 
ward, but  the  resonance  gener- 
ally remains  box-like  for  a 
considerable  period.  Gradual 
restoration  of  the  vesicular 
murmur,  at  first  weak  and  dis- 
tant, then  somewhat  harsh,  and 
subsequently  of  a  normal  char- 
acter. Reappearance  of  the 
friction  sound  for  a  time. 
Pseud o  rales  occasionally  to  be 
heard.  iEgophony  sometimes 
to  be  heard,  more  often  bron- 
chophony, and  ultimately  nor- 
mal vocal  resonance. 


Post-mortem  Appearances. — 1st  stage.  Pleura  opaque  and  drier 
than  natural,  roughened  and  highly  vascular,  and  presenting  a  close  net- 
work of  blood-vessels  with  ecchymoses. 

2d.  Fluid,  either  serous  or  purulent,  mixed  with  shreds  of  creamy 
lymph,  in  the  cavity  of  the  pleura.  Lung  pushed  upward  and  back- 
ward towards  the  spine,  its  surface  coated  with  a  layer  of  lymph  of  the 
same  kind  as  that  mixed  with  the  fluid.    The  lung  collapsed  and  carnified. 

3d.  If  the  effusion  has  been  of  long  duration  the  lung  remains  carni- 
fied and  bound  down  by  adhesions,  and  the  chest-wall  undergoes  retrac- 
tion or  depression,  the  ribs  overlap,  and  there  is  more  or  less  lateral 
curvature  of  the  dorsal  spine  toward  the  diseased,  and  of  the  lumbar 
toward  the  healthy,  side. 

The  diagnosis  can  be  made  by  drawing  off  part  of  the  fluid  from  the 
chest  by  means  of  a  hypodermic  syringe.  If  purulent,  it  should  be 
evacuated,  or  it  may  lead  to  amyloid  change  in  the  liver  and  kidneys. 

The  effusion  may  become  purulent  at  first;  there  are  no  reliable  means 
of  recognizing  the  exact  time  when  this  occurs,  but  later  it  assumes  all 
the  characteristics  of  empyema,  as  follows : — 


1G0 


•DIFFERENTIAL    DIAGNOSIS. 


Empyema. 


PHYSICAL   SIGNS. 


More  decided  febrile  dis- 
turbance of  a  hectic 
type,  night  sweats. 
Morning  remission  and 
evening  exacerbations. 
Face  puffy  and  semi- 
transparent.  Clubbing 
of  the  finger  ends.  If 
pointing  inwardly, 
abundant  purulent 
sputa. 


The  physical  signs  are  those  of 
the  stage  of  effusion.  The  di- 
agnosis is  often  to  be  deter- 
mined only  with  the  aid  of  the 
aspirator,  or  the  hypodermic 
needle. 


DIAGNOSIS  BETWEEN  PLEURISY  WITH  EFFUSION  AND 
PNEUMONIC  CONSOLIDATION. 

PNEUMONIA. 
1.  Begins  with  a  severe  and  pro- 
tracted rigor. 


PLEURISY. 

1.  Begins  with  chilliness  or  seve- 
ral slight  rigors. 

2.  Sharp,  catching,  stitch-like 
pain  in  the  side. 

3.  Cough,  dry  or  with  little  mu- 
cous expectoration,  very  painful, 
and  repressed  by  the  patient. 

4.  Pyrexia  is  not  great  and  the 
skin  may  be  moist. 

5.  Excretion  of  chlorides  not 
affected. 

6.  Pulse-respiration  ratio  not  af- 
fected, except  in  excessive  effusion. 

7.  Affected  side  rounded;  dis- 
placement of  heart. 


8.  Feeble  or  absent  vocal  fremi- 


tus. 

9, 

sion 


Absolute  dullness  on  percus- 
transgressing  the  median  line 
in  front. 

10.  Feeble  or  absent  vesicular 
breathing;  bronchial  breathing  at 
the  root  of  the  lunsr. 

1 1 .  Vocal  resonance  absent,  some- 
times segophonic. 


I.  Pain  does  not  catch  the  breath ; 
is  more  of  a  dull  character. 

3.  Cough  frequent  and  severe, 
with  rusty,  viscid  expectoration. 

4.  Great  febrile  disturbance,  skin 
hot  and  pungent. 

5.  Diminution  or  absence  of  chlor- 
ides in  the  urine. 

6.  Pulse-respiration  ratio  may 
fall  to  2  :  1. 

7.  No  alteration  in  shape  of  the 
chest  or  of  the  intercostal  spaces ; 
heart  not  displaced. 

8.  Vocal  fremitus  usually  much 
intensified. 

9.  Less  intense  dullness,  not  trans- 
gressing the  median  line. 

10.  Marked  tubular  breathing, 
often  of  a  metallic  character. 

II.  Loud  bronchophony. 


DISEASES    OF   THE    RESPIRATORY    APPARATUS. 


Hil 


DIAGNOSIS  BETWEEN  PNEUMONIA   AND   PULMONARY 
APOPLEXY.     (PULMONARY  EMBOLISM.) 


PULMONARY  APOPLEXY. 

Nearly    always    associated    with 
heart  disease  or  pyaemia. 

Fever  absent  ex- 
Pulse   irregular 


Onset  sudden, 
cept   in    pyaemia, 
and  intermittent. 

Expectoration 
small  dark  clots. 


blackish,     with 


Dyspnoea  severe  at  first,  after- 
wards diminishing;. 

Dullness  distinctly  circumscribed ; 
respiration  bronchial,  with  moist 
rale. 

A  peculiar  acid  and  alliaceous 
odor  to  the  breath  "  like  the  smell 
of  tincture  of  horse  radish"    (Gue- 

NEAU  DE  MUSSY). 


PNEUMONIA. 

Generally  an  independent  disci-'; 
in  robust  individuals. 


Onset  with  malaise  and  chill, 
ver.     Pulse  rapid. 


Fe- 


Expecto  ration 
clots. 


rust-colored ;    no 


Dyspnoea  gradually  grows  in  in- 
tensity. 

Dullness  larger  and  extending. 
Crepitant  rale.  Tubular  breathing, 
bronchophony. 

Not  present. 


THROMBOSIS  OF  PULMONARY  ARTERY. 

The  symptoms  of  an  immediately  fatal  attack  are:  Sudden  extreme 
dyspnoea  with  open  tubes,  cough  and  thoracic  pain,  lividity  or  pallor, 
rapidly  failing  pulse,  cold  sweats,  intense  anxiety,  and  attacks  of  faint- 
ing or  unconsciousness,  with  or  without  spasms. 

In  the  diagnosis,  the  suddenness  of  the  conditions  being  of  the  chief 
interest,  all  those  forms  of  suffocation  requiring  time  for  their  production 
may  be  disregarded,  and  there  remain : — 

1.  Closure  of  the  greater  air  passages  or  of  a  large  number  of  small 
ones,  from  without  or  from  within. 

2.  Nervous  lesions,  particularly  intra-cranial,  affecting  respiration  and 
circulation. 

3.  Obstruction  to  the  pulmonary  circulation  from  emboli,  of  blood  and 
air  particularly,  fat  being  more  gradual  in  its  effects. 

Physical  and  rational  evidence  of  open  air  passages  eliminate  the  first 
series.     In  intra-cranial   origins   of  suffocation  the  predominant   early 


162  DIFFERENTIAL   DIAGNOSIS. 

symptoms  are  those  of  cerebral  amemia,  namely,  pallor,  relaxed  muscles, 
disturbed  Inuring-  and  vision,  contracted  pupils,  fainting  and  convul- 
sions. Dyspnoea  may  sometimes  preeede  these  symptoms,  but  it  is  not  of 
so  severe  a  character  as  in  the  other  series. 

In  favor  of  the  third  is  the  history  of  an  antecedent  thrombus,  or  of  a 
disease  of  the  heart  likely  to  be  associated  with  thrombosis  or  of  septi- 
caemia. 

ASTHMA. 
SYMPTOMS.  PHYSICAL  SIGNS. 

There  may  be  premonitory  sy mp-  !  Chest  generally  distended,  though 
tonis,  such  as  gradually  increasing  there  is  scarcely  any  expansive  move- 
dyspnoea  or  the  passing  of  a  large  iment.  Recession  of  the  intercostal 
quantity  of  limpid  urine;  but  the  spaces,  supra-sternal  and  supra-cla- 
attacks  usually  come  on  suddenly  at '  vicular  fossa?  and  epigastrium  dur- 
an  early  hour  in  the  morning;  the  ing  inspiration,  which  is  short  and 
patient  *  awakes  in  a  start,  with  a  I  jerky,  while  expiration  is  prolonged 
sensation  of  suffocation  and  oppres-  |  and  wheezing.  Vocal  vibration  not 
siveness  of  the  chest;  he  either  sits  markedly  affected.  Rhonchal  frem- 
upright  in  bed,  or  sometimes  itus  may  be  felt.  Resonance  on  per- 
stands  holding  on  to  a  piece  of  cussion  increased  all  over  the  chest, 
furniture,  so  as  to  bring  into  play  Almost  complete  absence  of  vesicu- 
the  accessory  muscles  of  respira-  lar  murmur.  Every  variety  and 
tiou.  Countenance  pale  and  anx-  i  kind  of  sibilus  and  rhonchus,  whis- 
ious;  in  bad  cases  cyanotic.  Skin  tling,  squeaking,  cooing,  snoring 
covered  with  sweat;  extremities  sounds,  and  occasionally  mucous 
cold.  Pulse  frequently  feeble.  The  rales  towards  the  termination, 
attacks  generally  terminate  with  the 
expulsion  of  tough,  ashy  gray  pel- 
lets of  mucus. 

Post-mortem  Appearances. — The  appearances  found  after  death 
are  principally  the  result  of  chronic  bronchitis  and  emphysema,  with  di- 
latation of  the  right  side  of  the  heart. 

PNEUMOTHORAX. 

This  condition  is  generally  found  with  serous  effusions — pneumo- 
hydrothorax;  but  occasionally  presents  itself  as  an  independent  affection. 
The  characteristics  of  the  two  forms  are  as  follows : — 


DISEASES   OF   THE   RESPIRATORY  APPARATUS. 


163 


Symptoms. 


Physical 
Signs. 


PNEUMOTHORAX. 


Generally  sharp,  stabbing 
pain,  with  the  sensation  of 
something   having  given 
way.      Urgent    dyspnoea 
and   evidences  of  shock. 
More  or  less  cyanosis.  Pos- 
ture assumed   by  patient 
varies.      Pulse   frequent, 
weak  and  small.  Respira- 
tion may  be  40  to  60  in 
the  minute.  Troublesome 
cough  without  expectora- 
tion.    In   some   cases   of 
phthisis,   or  where  there 
are  extensive  pleural  adhe- 
sions, pneumothorax  may 
come  on  quite  impercepti- 
bly. 
Dilatation  of  the  affected 
side,  with  obliteration  or 
bulging  of  the  intercostal 
spaces.  Movements  of  res- 
piration diminished  or  ab- 
sent.   Increased  elasticity 
of  the  walls  of  the  chest. 
Feeble   or    absent   vocal 
fremitus.    Clear  tympan- 
itic resonance  on  percus- 
sion. If  the  amount  of  air 
is  extreme  there  may  be 
high-pitched  dullness.  No 
true   vesicular    murmur ; 
bronchial   breathing  may 
be  heard  along  the  spine. 
Amphoric    sounds,    with 
inspiration,     voice,     and 
cough,     also   a     metallic 
echo ;  the  bell  sound  may 
be   elicited.    The  neigh- 
boring  viscera    are    dis- 
placed to  a  variable  degree. 


PNEUMO-HYDROTHORAX. 

Symptoms  the  same,  except 
that  the  cough  is  usually  at- 
tended by  fetid,  puriform 
expectoration.  The  patient 
lies  on  or  toward  the  af- 
fected side. 


Same  as  in  true  pneumotho- 
rax, except  that  percussion 
is  dull  in  the  lower  part  of 
the  chest,  and  tympanitic 
above  the  level  of  the  fluid. 
Metallic  tinkling  and 
splashing  sounds  on  suc- 
cussion  are  also  frequently 
heard. 


1G4 


DIFFERENTIAL   DIAGNOSIS. 


PNEUMOTHORAX— [Cntim/cl). 


PNEUMOTHORAX. 


Post-mortem 
appearance. 


Lung  collapsed,  lying  near 
vertebral  column,  unless 
bound  down  by  old  adhesions 
to  some  other  part  of  the 
chest  wall.  The  gas  is  com- 
posed chiefly  of  carbonic 
acid  and  nitrogen,  containing 
but  little  oxygen,  and  occa- 
sionally some  sulphureted 
hydrogen. 


I •  N  1 : 1   M(>-IIYI>i:c>TIIOKA\. 


Lung  collapsed.  Air, 
mixed  with  fluid,  in 
pleural  cavity.  Mostly 
arises  as  a  termination 
to  phthisis,  a  superficial 
cavity  becoming  rup- 
tured. May  occur  in 
pneumonia,  emphyse- 
ma, or  gangrene  of 
the  lung,  and  more 
rarely  in  other  diseases. 


EMPHYSEMA. 

This  affection  presents  itself  in  two  forms,  the  vesicular  and  the  inter- 
lobular, which  are  distinguished  as  follows  : — 


Symptoms. 


VESICULAR    EMPHYSEMA. 


Habitual  shortness  of  breath, 
with  occasional  paroxysms  of 
urgent  dyspnoea,  most  fre- 
quently supervening  on  ca- 
tarrh. Cough,  with  or  with- 
out expectoration  of  thin, 
transparent,  frothy  mucus. 
In  the  last  stage  of  the  dis- 
ease there  are  symptoms  due 
to  interference  with  the  cir- 
culation, as  palpitation,  cyan- 
osis, general  dropsy,  and  con- 
gestion of  the  abdominal  vis- 
cera. The  disorder  is  essen- 
tially chronic  in  its  course, 
and  may  progress  so  slowly 
as  not  to  materially  shorten 
life.  It  generally  occurs  in 
persons  who  are  otherwise 
vigorous,  and  is  hence  sup- 
posed to  grant  immunity 
from  consumption. 


INTERLOBULAR    EMPHYSEMA. 


Urgent  dyspnoea  and 
oppression,  generally 
occurring  suddenly 
after  some  violent 
effort,  the  subcutane- 
ous areolar  tissue  fre- 
quently becoming 
oedematous. 


DISEASES    OF  THE   RESPIRATORY   APPARATUS. 


165 


EMPHYSEMA— ( Continued). 


Physical 
Signs. 


Post-mortem 
appearance. 


VESICULAR    EMPHYSEMA. 


Chest  "  barrel  shaped"  and  al- 
most circular.  Sternum  pro- 
jecting forward.  Sea  puke 
and  clavicles  raised  and  ill- 
defined.  Ribs  more  horizon- 
tal and  intercostal  spaces 
widened.  Respiration  ab- 
dominal. Movement  of  chest 
much  diminished.  Heart 
beating  in  the  epigastric  re- 
gion. Resonance  on  percus- 
sion greatly  increased  or 
tympanitic.  Feeble  inspira- 
tion, prolonged  expiration, 
the  former  wheezing,  the 
latter  generally  with  rhon- 
chus  or  sibilus.  Vocal  fre- 
mitus and  resonance  usually 
deficient. 

Lung  does  not  collapse  as  usual 
when  the  chest  is  opened,  but, 
on  the  contrary,  may  rise  up 
and  bulge  out  of  its  cavity. 
It  is  pale  and  ansemic,  and 
does  not  crepitate  when 
pressed,  but  feels  soft  and 
downy,  and  is  drier  than  or- 
dinary. The  air  cells  are 
dilated,  or  several  have  be- 
come one  cavity  from  the 
rupture  of  the  septa  between 
them.  Cells  vary  from  the 
size  of  a  millet-seed  to  that 
of  a  swan-shot,  or  larger. 


INTERLOBULAR    EMPHYSEMA. 

Percussion       tympanitic 
over  the  affected  part. 


Bead-like  bubbles  of  air 
seen  through  the  pleu- 
ra, or  partitions  be- 
tween the  lobules  much 
widened.  Sometimes 
air  is  found  beneath 
the  areolar  tissue  of 
the  neck. 


CANCER  OF  THE  LUNG. 

The  principle  obstacle  in  recognizing  this  disease  is  the  liability  to 
confound  it  when  primary  and  unilateral  (as  it  usually  is  when  primary) 


166  DIFFERENTIAL   DIAGNOSIS. 

with  phthisis.      Similar   cough,  emaciation,  haemoptysis,  night  sweats, 
etc,  occur  in  both.     The  points  of  difference  are: — 

PULMONARY  CANCER.  PHTHISIS. 


Sides  of  chest  more  markedly 
asymmetrical ;  the  tumor  may  bulge 
through  the  intercostal  spaces. 

Percussion  dullness  very  great; 
may  extend  beyond  median  line. 

Frequent  changes  in  the  signs  of 
auscultation,  rales,  bruits,  etc. 

Hsemoptoic  sputa,  "  resembling 
currant  jelly." 

Pain  constant,  severe,  lancinat- 
ing. 

Cancerous  cachexia,  tinge  of  skin, 
etc. 


One  side  may  be  sunken ;  never 
bulging. 

Percussion     dullness     moderate; 
never  extends  beyond  median  line. 

Changes  much  more  gradual. 

Sputa  never  present  this  appear- 
ance. 

Pain  variable,  intermittent. 
Absent. 


Pulmonary  cancer  is  sometimes  so  masked  that  its  diagnosis  requires 
the  closest  attention.  It  may  be  present  without  the  characteristic  sputa, 
without  cachexia,  and  even  without  pain  at  cancerous  spot.*  Such  in- 
stances are,  of  course,  very  rare. 

It  is  liable  to  be  mistaken  for  chronic  pleurisy,  or  vice  versa.  The 
distinguishing  features  are,  that  in  cancer  there  is  an  absence  of  the  com- 
plete consolidation  of  chronic  pleurisy;  the  consolidation  of  the  latter  is  at 
the  lower  portion  of  the  lung;  the  expectoration  of  cancer  is  quite  dif- 
ferent from  that  of  pleurisy  and  bronchitis;  and  the  previous  history, 
both  of  the  individual  and  his  family,  in  cancer,  points  to  this  disease, 
while  chronic  pleurisy  has  as  an  antecedent  an  acute  attack. 

The  deposits  of  gummatous  nodules  in  the  lungs  consequent  on  second- 
ary syphilis,  together  with  the  cachexia  attendant  on  that  disease,  may 
simulate  a  cancerous  deposit.  The  history  of  the  case,  the  presence  of 
syphilitic  signs  in  other  organs  and  tissues,  and  the  fact  that  cancers  tend 
to  spread  and  infiltrate  the  surrounding  tissue,  while  the  syphilitic  nodule 
remains  isolated  and  circumscribed,  are  the  distinctive  points. 

*  See  case  recorded  in  the  Boston  Medical  and  Surgical  Journal,  January,  1876. 


DISEASES    OF  THE   CIRCULATORY   APPARATUS. 


1  07 


CHAPTER  III. 

DISEASES  OF  THE   CIRCULATORY  APPARATUS. 

Contents. —  The  Prcecordial  Region — Normal  Sounds  and  Impulse  of 
the  Heart — Endocardial  Murmurs — General  Rules  for  the  Diagnosis 
of  Heart  Diseases — Constitutional  Symptoms  of  Heart  Disease — Club- 
bing of  the  Fingers — Differential  Signs  Between  Anoemic  and  Organic 
Blood  Murmurs — Pain  at  and  near  the  Heart — Aphorisms  Regarding 
Angina  Pectoris — Differential  Signs  of  Aortic  Obstruction  and  Aortic 
Incompetency;  of  Mitral  Obstruction  and  Mitral  Incompetency;  of 
Pulmonary  Obstruction  and  Tricuspid  Regurgitation — Pericarditis — 
Diagnosis  Between  Acute  Endocardial  and  Exocardial  Sounds;  Between 
Cardiac  Dilatation  and  Pericarditis  with  Effusion;  Between  Simple 
Hypertrophy,  Hypertrophy  with  Dilatation,  and  Simple  Dilatation — 
Fatty  Degeneration  of  the  Heart. 

The  anatomical  positions  of  the  several  parts  of  the   heart  are   as 
follows : — 

RELATIONS  OF  THE  HEART  TO  THE  PRECORDIAL  REGION. 


REGION. 

Apex  of  Heart.... 

Base  of  Heart 

Tricuspid  Orifice. 

Mitral  Orifice.... 


SITUATION. 


Between  fifth  and  sixth  ribs  on  left  side,  about 
two  inches  below  the  nipple  and  one  inch 
on  its  sternal  side. 

On  a  level  with  the  third  costal  cartilages. 

Extends  from  the  junction  of  the  fourth  left 
costal  cartilage  with  the  sternum,  behind 
that  bone  to  the  articulation  of  it  with  the 
sixth  right  cartilage. 

To  the  left  of  the  tricuspid  valves,  immedi- 
ately behind  the  fourth  costal  cartilage ; 
but  less  superficially  placed  than  the  tri- 
cuspid. 


168 


M  ll'Ki:  KNTIAL    DIAGNOSIS. 


TIIK  l'K.ECORDIAL  REGION— {Continued  i. 


REGION. 


Pulmonary  Orifice. 


Aortic  Orifice. 


Immediately  behind  the  left  border  of  the 
sternum  at  the  junction  of  the  third  costal 
cartilage  with  that  bone. 

About  half  an  inch  lower  than  and  to  the 
right  of  the  pulmonary  orifice,  behind  the 
sternum,  on  a  level  with  the  third  inter- 
space. 

Let  it  be  remembered  that  the  tricuspid  orifice  is  the  most  superficial, 
then  the  pulmonary,  next  the  aortic,  and  deepest  of  all  is  the  mitral 
orifice.  Ranged  from  above  downward,  the  pulmonary  orifice  comes 
first,  then  the  aortic,  then  the  mitral,  and  lastly  the  tricuspid. 

PHYSICAL  EXAMINATION  OF  PRECORDIAL  REGION. 


EXAMINATION-    BY 


Inspection Form  of  chest. 

Point  at  which  the  apex  of  the  heart  strikes 

the  wall  of  the  chest. 
Regularity  of  impulse,  and  extent  over  which 
it  is  perceptible. 

Palpation Force  and  regularity  of  impulse. 

Presence  or  absence  of  purring  tremor  or  of 
friction  fremitus. 


Percussion 

Auscultation 


Extent  and  intensity  of  precordial  dullness. 

Character  of  rhythm. 

Character  of  sounds,  normal  or  abnormal, 


THE  AREA  OF  SUPERFICIAL  CARDIAC  DULLNESS 

Is  roughly  triangular  in  shape,  the  right  side  of  the  triangle  being  the 
mid-sternal  line  from  the  level  of  the  fourth  chondro-sternal  articulation 
downward;  the  hypothenuse  being  a  line  drawn  from  the  same  articula- 
tion to  a  point  immediately  above  the  apex-beat;  the  base  being  a  line 
drawn  from  immediately  below  the  apex-beat  to  the  point  of  meeting  be- 
tween the  upper  limit  of  liver  dullness  and  the  mid-sternal  line  (Dr.  Gee). 


DISEASES   OF  THE   CIRCULATORY    APPARATUS. 


169 


NORMAL  SOUNDS  AND  IMPULSK  OF  FIKAKT. 


POINT   OF 

„       CONDITION  OFCIRCCT- 

SOUND. 

CHARACTER. 

GREATER   IN- 
TENSITY. 

CAUSE. 

TJ.MK. 

J.ATION. 

First  Sound. 

Dull  and  pro- 

Fourth   and  Closure  of  auri- 

A 

Contraction  of  ven- 

(Systolic). 

longed. 

fifth    inter- 

culo-ventricu- 

tricles,    following 

costal 

lar  valves, and, 

that   of    auricles. 

spaces  just 

perhaps,  mus- 

Closure of  auricu- 

within    left 

cular  contrac- 

1  o -  ventricular 

nipple  line. 

tion  of  the 
ventricles 
themselves; 
also  impact  of 
apex   against 
the  chest-wall, 
and    vibration 
of  papillary 
muscles     and 
chorda    ten- 
dineae. 

valves,  open  aor- 
tic and  pulmonary 
valves;  propul- 
sion of  blood  into 
the  arteries.  Im- 
pulse of  the  heart 
immediately  fol- 
lowed by  pulse  at 
the  wrist. 

First  Pause. 

1 

Auricles  dilating. 

Second  Sound 

Short  and  Base ofheart, 

Sudden    closure 

2 

Filling  of  both  au- 

(Diastolic). 

clear. 

opp  o  site 

of   the    aortic 

ricles  and  ventri- 

the third 

and    pulmo- 

cles.    Closure   of 

right  costal 

nary  valves. 

arterial  valves, 

cartilage. 

opening  of  auri- 
c  u  1  o- ventricular 
valves. 

Second  Pause 

A 

Complete  distention 
of  auricles,  fol- 
lowed by  their 
contraction,  and 
distention  of  ven- 
tricles. Auriculo- 
ventricular  valves 
open,  arterial 
valves  closed. 

Impulse. 

Between  fifth 
and     sixth 
ribs  on  left 
side,  about 
one   and  a 
half  or  two 
inches   be- 
low    the 
nipple,  and 
one  inch  to 
its   inner 
side. 

In  part  due  to  the 
tilting  upward 
of   the    apex, 
but   chiefly  to 
the    recoil    of 
heart   and 
change    in 
shape,    for 
during  the  sys- 
tole it  becomes 
harder  and 
more    globu- 
lar. 

170 


DIFFERENTIAL    DIAGNOSIS. 
ENDOCARDIAL  MURMURS. 


TIME. 

SITUATION'. 

ORIFICE. 

NATURE. 

SvSTOl.li'                  1       . 

2 

3  ! 

4  . 

DlASTOl  H               1      . 

Presystolic      1    . 

Basic  (right). 

•■     licit). 
Apical. 

Basic. 
Apical. 

Aortic. 
Pulmonary. 

Mitral. 
Tricuspid. 

Aortir. 
Mitral. 

Obstructive. 

a 
Regurgitant. 

a 
Obstructive. 

Pulmonary  regurgitant  murmur  (diastolic)  and  tricuspid  obstructive 
murmur  (presystolic)  are  very  rarely  met  with  clinically,  and  for  all 
practical  purposes  they  may  be  disregarded. 

The  most  frequent  combinations  of  these  murmurs  are: — 

1.  Combined  aortic  obstruction  with  regurgitation. 

2.  Mitral  obstruction  and  regurgitation. 

3.  Various  combinations  of  the  two  preceding  forms,  the  aortic  and 
mitral  valves  being  both  diseased. 

4.  Mitral  obstruction  with  dilated  right  ventricle,  and  consequently 
tricuspid  regurgitation  (Dr.  Aitkex). 

Order  of  frequency  of  endocardial  murmurs,  commencing  with  the 
most  common  : — 


1.  Mitral  regurgitant. 

2.  Aortic  constrictive. 

3.  Aortic  regurgitant. 

4.  Mitral  constrictive. 


5.  Tricuspid  regurgitant. 

6.  Pulmonary  constrictive. 

7.  Pulmonary  regurgitant. 

8.  Tricuspid  constrictive. 

Order  of  relative  gravity  as  "estimated  not  only  by  their  ultimate 
lethal  tendency,  but  by  the  amount  of  complicated  miseries  they  inflict." — 
Dr.  AValshe. 


1.  Tricuspid  regurgitation. 

2.  Mitral    constriction    and    re- 
gurgitation. 


3.  Aortic  regurgitation. 

4.  Pulmonary  constriction. 

5.  Aortic  constriction. 


GENERAL   RULES   FOR   THE   DIAGNOSIS   OF   HEART 

DISEASE. 

Dr.  John-  Hughes  Bennett*  gives  the  following  rules : — 

1.  In  health  the  cardiac  dullness,  on  percussion,  measures,  immediately 

*  "  Lectures  on  the  Principles  and  Practice  of  Medicine." 


DISEASES   OF  THE   CIRCULATORY  APPARATUS.  171 

below  the  nipple,  two  inches  across,  and  the  extent  of  dullness  beyond 
this  measurement  commonly  indicates  either  the  increased  size  of  the 
organ  or  undue  distention  of  the  pericardium. 

2.  In  health  the  apex  of  the  heart  may  be  felt  and  seen  to  strike  the 
chest  between  the  fifth  and  sixth  ribs,  a  little  below  and  a  little  to  the 
inside  of  the  left  nipple.  Any  variations  that  may  exist  in  the  position 
of  the  apex  are  indications  of  disease  either  of  the  heart  itself  or  of  the 
parts  around  it. 

3.  A  friction  murmur  synchronous  with  the  heart's  movements  indi- 
cates pericardial  or  ex-pericardial  exudation. 

4.  A  bellows  murmur  with  the  first  sound  heard  loudest  over  the 
apex  indicates  mitral  insufficiency. 

5.  A  bellows  murmur  with  the  second  sound  heard  loudest  at  the 
base  indicates  aortic  insufficiency. 

6.  A  bellows  murmur  with  the  second  sound  heard  at  the  apex  is  rare. 
It  indicates — 1st,  aortic  disease,  the  murmur  being  propagated  downward 
to  the  apex ;  or  2d,  roughened  auricular  surface  of  the  mitral  valves ;  or 
3d,  mitral  obstruction. 

7.  A  murmur  with  the  first  sound  loudest  at  the  base,  and  propagated 
in  the  direction  of  the  large  arteries,  is  more  common.  It  indicates — 1st, 
an  altered  condition  of  the  blood,  as  in  anaemia ;  or  2d,  dilatation  or  dis- 
ease of  the  aorta  itself;  or  3d,  stricture  of  the  aortic  orifice,  or  disease  of 
the  aortic  valve. 

8.  Hypertrophy  of  the  heart  may  exist  independent  of  any  valvular 
lesion,  but  this  is  rare. 

9.  The  pulse  as  a  general  rule  is  soft  and  irregular  in  mitral  disease, 
but  hard,  jerking,  or  regular  in  aortic  disease. 

10.  Cerebral  symptoms  are  more  marked  in  aortic  disease ;  pulmonary 
symptoms  in  mitral  disease. 

Various  constitutional  symptoms  should,  in  default  of  other  obvious 
causation,  lead  to  the  suspicion  of  disease  of  the  heart.    These  are  mainly : 

1.  Symptoms  referred  to  the  circulation.  Violent,  continued  pulsation 
may  arise  from  cardiac  hypertrophy,  and  especially  aortic  regurgitation. 
Cyanosis,  blueness  of  the  lips,  coldness  of  the  finger  tips,  etc.,  are 
common  in  many  cardiac  cases.  Dropsy  is  a  late  and  dangerous  symp- 
tom. 


172  DIFFERENTIAL   DIAGNOSIS. 

2.  Symptoms  referred  to  the  lungs.  These  are  frequent  cardiac  com- 
plications, especially  dyspnoea,  orthopnoea  and  cough. 

3.  Symptom*  referred  to  the  brain.  Vertigo,  languor,  chorea,  epilepsy, 
apoplexy  and  paralysis  may  all  be  brought  about  by  heart  disease.  In 
sudden  cerebral  attacks  in  patients  suffering  with  valvular  disease,  embol- 
ism is  often  at  work. 

4.  Stomach  symptoms.  Dyspepsia  and  hemorrhoids  may  find  their 
origin  in  cardiac  lesions. 

5.  Throat  symjytoms.  Pain  in  the  throat  is  complained  of  in  angina; 
hoarseness  and  aphonia  sometimes  signify  pericarditis. 

6.  Renal  symptoms  may  follow  heart  disease.  In  all  cases  of  cardiac 
disease  the  urine  should  be  tested  for  albumen,  as  this  condition  may 
excite  cardiac  symptoms.* 

CLUBBING  OF  THE  FINGER  ENDS  IN  CHRONIC  HEART 
DISEASE  AND  PHTHISIS. 

The  following  aphorisms  on  this  point  are  laid  down  by  Dr.  Horace 
DoRELL:f — 

Aphorism  I.  Clubbing  of  the  finger  ends  on  one  or  both  sides  of  the 
body,  with  or  without  incurvations  of  the  nails,  may  occur  whenever  the 
return  of  blood  by  one  or  both  subclavian  veins  is  seriously  obstructed 
for  a  considerable  length  of  time. 

II.  Symmetrical  clubbing  of  the  finger  ends  of  both  hands  without 
incurvation  of  the  sides  and  tips  of  the  nails,  is  presumptive  evidence  of 
the  existence  of  heart  disease. 

III.  Clubbing  of  the  finger  ends  without  incurvature  of  the  sides 
and  tips  of  the  nails  is  presumptive  evidence  against  the  existence  of 
phthisis. 

IV.  Symmetrical  clubbing  of  the  finger-ends  conjoined  with  incurv- 
ation of  the  sides  and  tips  of  the  nails,  is  a  sign  that  obstruction  of  the 
return  blood  by  the  subclavian  veins  and  wasting  of  adipose  tissue  have 
co-existed. 

*See  also  paper  by  Prof.  Da  Costa  and  Dr.  LoNGSTRETH  in  Am.  Journal  for  Med. 
Scieiices,  for  July,  1880,  for  pathological  relationship  of  heart  disease  and  chronic 
kidney  disorder. 

f  "  Affections  of  the  Heart.''     London,  187G. 


DISEASES   OF   THE   CIRCULATORY   APPARATUS. 


173 


DIFFERENTIAL  SIGNS  BETWEEN  ANiEMIC  AND 
OEGANIC  CARDIAC  SOUNDS. 


ANiEMIC  SOUNDS. 

First  sound  heard  over  the  right 
ventricle  is  distinct,  second  ringing; 
a  soft  murmur  is  heard  over  the  left 
ventricle. 

Sounds  vary  in  character. 

Sounds  increase  in  intensity  in 
following  the  aorta. 

Pressure  with  the  stethoscope  in- 
creases or  developes  the  sound. 

Bruit  du  (Liable,  a  continuous 
musical  hum,  can  be  heard  in  the 
hollow  above  the  right  clavicle. 

Co-existence  of  pallor  or  anaemia; 
amenorrhoea;  leucorrhoea;  nervous 
exhaustion;  chorea;  renal  disease; 
phthisis. 


ORGANIC  SOUNDS. 

Murmur  generally  harsh  and 
blowing,  and  takes  the  place  of  one 
or  both  sounds  of  the  heart.  It  may 
be  distinctly  located*  at  apex  or  base. 

Sound  the  same  after  several  ex- 
aminations. 

Sounds  diminish  in  intensity  in 
receding  from  the  heart. 

Not  affected  by  pressure. 

Not  present. 


Co-existence  of  alteration  in  size 
of  the  heart;  other  organic  signs; 
history  of  rheumatism. 


PAIN  AT  THE  HEART. 

Pain  is  by  no  means  a  common  symptom  of  heart  disease.  Not  more 
than  one  in  a  dozen  cases  of  chronic  organic  cardiac  disease  complain  of 
pain  at  all.*  In  acute  cardiac  affections  it  is  more  frequent.  In  most 
cases  of  alleged  pain  at  the  heart,  it  is  found  on  examination  to  proceed 
from  dyspepsia,  muscular  rheumatism,  intercostal  neuralgia,  enlarged 
spleen,  or  the  like. 

APHORISMS   OF   DR.   HORACE   DOBELL.f 

I.  Pain  in  the  region  of  the  heart  and  down  the  left  arm  does  not 
necessarily  indicate  heart  disease. 

II.  The  conjunction  of  pain  in  the  region  of  the  heart  and  pain  in  the 
left  arm  may  be  a  most  important  symptom  of  heart  disease,  and  is  never 
to  be  disregarded. 


*  Sansom,  "  Diagnosis  of  Diseases  of  the  Heart,"  p.  3. 
f  "  On  Affections  of  the  Heart."     London,  1876. 


174  DIFFERENTIAL   DIAGNOSIS. 

III.  It'  pain  is  excited  by  exercise  taken  when  the  stomach  is  not  dis- 
tended with  food  <>r  gas,  and  especially  if  it  comes  on  quickly  and  iu- 
creases  steadily  in  severity  with  the  continuance  of  exercise,  it  is  almost 
certain  there  is  some  serious  disease  of  the  circulatory  organs. 

IV.  When  it  is  found  that  flatulence  or  a  full  meal  embarrasses  the 
heart  painfully,  a  careful  investigation  should  be  made  into  the  condition 
both  of  the  organ  itself,  and  of  the  blood. 

V.  Important  heart  disease  may  exist,  and  yet  pain  at  the  heart  aud 
in  its  neighborhood  be  absent. 

VI.  The  appalling  import  of  pain  in  the  throat  in  heart  disease  in- 
creases in  proportion  as  the  period  of  its  onset  deviates  from  the  follow- 
ing order  of  severity : — 

1.  Pain  under  the  left  breast. 

2.  Pain  extending  from  under  the  left  breast  to  mid-sternum. 

3.  Pain  extending  from  mid-sternum  toward  the  left  shoulder. 

4.  Pain  extending  from  the  left  shoulder  down  the  left  arm. 

5.  Pain  extending  from  mid-sternum  toward  the  right  shoulder. 

6.  Pain  extending  from  the  left  shoulder  down  the  right  arm. 

7.  Pain  extending  up  the  sternum  toward  the  region  of  the  throat. 

8.  Pain  in  the  thyroid  cartilage. 

AVhen  this  order  of  advance  is  maintained  as  the  exciting  cause  is  con- 
tinued, pain  in  the  throat  expresses  the  degree  of  dangerous  persistence  in 
the  exciting  cause  of  heart  distress,  rather  than  the  degree  of  danger  in 
the  disease  itself. 

VII.  In  proportion  as  the  right  side  of  the  chest  and  right  arm  take 
precedence  in  the  order  of  extension  of  pain  at  the  heart  and  its  neigh- 
borhood, the  probability  increases  that  the  aorta  is  more  diseased  thin 
the  heart. 

VIII.  The  volume  of  blood  and  other  conditions  being  normal,  the 
facility  with  which  the  pulse  at  the  wrist  is  stopped  by  inspiration 
measures  the  loss  of  heart  power. 

ANGINA  PECTORIS. 

This  disease  is  usually  epioted  as  oue  typically  connected  with  pain  at 
the  heart.  This  is  by  no  means  the  case,  as  in  many  instances  there  is 
merely  a  sense  of  precordial  distress,  but  no  actual  pain  (Sansom).  The 
diagnostic  characters  are  : — 


DISEASES   OF    THE    CIKCULATOEY   APPARATUS. 


175 


1.  The  attacks  arc  paroxysmal,  coming  on  at  varying  intervals  and 
duration  (from  a  minute  to  an  hour),  without  assignable  cause. 

2.  There  is  always  a  sensation  of  coldness  experienced,  and  often  a 
cold  sweat. 

3.  The  heart's  action  is  not  increased,  and  may  be  diminished. 

4.  The  chest  is  fixed  and  the  breathing  slow. 

5.  The  pain,  when  present,  may  be  of  great  intensity,  of  a  cold,  sick- 
ening character,  directly  referred  to  the  heart,  with  an  accompanying 
sense  of  impending  dissolution. 

Though  at  first  a  neurosis,  probably  of  the  sympathetic  (cardiac 
ganglia)  angina  pectoris,  is  generally  associated  with  some  progressive 
defeneration  of  the  muscular  texture  of  the  heart. 


DIFFERENTIAL    SIGNS    OF    AORTIC    OBSTRUCTION   AND    AORTIC 

INCOMPETENCY. 


AORTIC    OBSTRUCTION. 


Hypertrophy  of  left  ven-E 
tricle. 


To  left. 

To  left  greatly. 

Forcible. 


To  left  of  sternum. 
Onward,  ventriculo-aortic. 

Systolic ;  loudest  at  begin- 
ning of  systole. 

Right  border  of  sternum, 
in  second  intercostal 
space. 

Upward  to  right  sterno- 
clavicular articulation. 


Apex  Displaced. 

Cardiac     Dullness 
Increased. 


Character   of  Im- 
pulse. 

Impulse  Felt. 

Murmur,  its  Direc- 
tion. 

Time  of  Murmur. 


Point  of  Greatest 
Intensity. 


Direction  in  which 
Propagated. 


AORTIC    INCOMPETENCY. 


Hypertrophy  and  dilatation 
of  left  ventricle. 

Downward  and  to  left. 

Downward  and  to  left, 
more  increased  than  in 
obstruction. 

More  forcible  than  in  ob- 
struction, and  over  wider 
area. 

To  left  of  sternum. 

Backward  ;  aortic-ventri- 
cular. 

Diastolic;  post-systolic; 
loudest  at  beginning  of 
diastole. 

Right  border  of  sternum 
opposite  third  intercostal 
space. 

Downward  along  sternum 
and  toward  apex. 


176 


DIFFERENTIAL    DIAGNOSIS. 


DIFFERENTIAL   SIGNS  OF  AORTIC  OBSTRUCTION  AND  AORTIC 
INCOMPETENCY— (Continued). 


AORTIC    OBSTRUCTION. 


Loud,  harsh,  or  blowing. 


Replaces  first  at  base. 


AORTIC    INCOMPETENCY. 


Character  of  Sound 
(very  uncertain 
and  of  little 
value  for  diag- 
nosis). 

Relation  to  Normal 
Heart  Sounds. 


Depends   on   condition  of  Effect   on    Second 
valves,  but  aortic  second,     Sound, 
sound   generally  feeble. 

Systolic;    in   second  right  Thrill, 
intercostal  space. 

Effects  on  Pulse 


Normal,   or    perhaps    de- 
creased. 

Diminished. 

Diminished. 

Regular. 

Slow. 

Arterial    amemia ;    angina 
pectoris  often  present. 


Frequency. 

Volume. 
Power. 
Rhythm. 
Duration. 
General  Tendency. 


Of  higher  pitch  than  in 
obstruction, ami  loudness 
decreases  rapidly  from 
commencement. 

Replaces  second  at  base, 
and  occupies  more  or 
less  of  the  pause. 

Apparent  intensification  of 
pulmonary  second. 

Down  sternum ;    diastolic. 

Visible  pulsation  in  arteries 
(locomotive  pulse). 

Normal,  or  perhaps  de- 
creased. 

Increased. 

Increased. 

Regular. 

Quick. 

As  in  obstruction,  but  sud- 
den death  more  common 
than  in  any  other  form 
of  valvular  disease. 


DIFFERENTIAL  SIGNS  BETWEEN   MITRAL  OBSTRUCTION  AND 
MITRAL  INCOMPETENCY. 


MITRAL    OBSTRUCTION'. 


Hypertrophy    and   dilata-  Effect  on  Heart, 
tion  of  left  auricle  andj 
right  chambers. 

To  left  and  slightly  down-  Apex  Displaced, 
ward. 


MITRAL    INCOMPETENCY. 


Hypertrophy  and  dilata- 
tion of  all  four  cham- 
bers. 

To  left  and  downward. 


DISEASES   OF  THE   CIRCULATORY   APPARATUS. 


177 


DIFFERENTIAL  SIGNS  BETWEEN  MITRAL  OBSTRUCTION  AND 
MITRAL  INCOMPETENCY—  {Continued ). 


MITRAL   OBSTRUCTION. 


To  right  of  sternum,  also 
to  left  at  base,  greatly. 

Feeble,    undulating,    and 

diffused. 
To  right  of  sternum  and  in 

epigastrium. 
Onward ;    auriculo-ventri 

cular. 
Diastolic,    presystolic, 

loudest  at  termination  of 

diastole. 
A  little  within  and  upward 

from  apex  beat. 
Upward    and  inward   to- 
ward right  base. 


Cardiac     Dullness 
Increased. 


Character  of    Im- 
pulse. 

Impulse,  where? 

Murmur,    its    Di- 
rection. 

Murmur,  Time. 


M ITRAL   INC  0  M  I'  BTE  N'C  Y. 


Generally 
harsh. 


rough    and 


Immediately  precedes  the 
first  at  apex,  which  is 
often  very  loud. 

Intensification  of  pulmo- 
nary second. 

Presytolic ;  upward  and 
inward  from  apex. 

Increased. 

Diminished. 

Diminished  greatly. 

Very  irregular. 

Quick. 

Pulmonary  and  venous 
congestion  and  slow 
death  by  asphyxia. 


Point  of  Greatest 
Intensity. 

Direction  in  which 
Propagated. 

Character  of  Sound 
(very  uncertain 
and  of  little  value 
for  diagnosis). 

RelationtoNormal 
Heart  Sounds. 


To  right  of  sternum,  and 
also  to  left  and  down- 
ward. 

Even  more  deficient  in 
force. 

Generally  increased  all 
over  cardiac  region. 

Backward;  ventriculo-au- 
ricular. 

Systolic,  loudest  at  begin- 
ning of  systole. 

A  little  outward  and  up- 
ward  from  apex  beat. 

Upward  toward  left  base, 
and  backward  into  ax- 
illa, and  behind. 

Blowing,  bellows  murmur. 


Effect    on 
Sound. 

Thrill. 


Second 


Effect  on  Pulse. 

Frequency. 

Volume. 

Power. 

Rhythm. 

Duration. 

General  Tendency 


Replaces  first  at  apex. 


Intensification 
nary  second. 

At   apex  and 
ilia. 


of   pulmo- 


toward  ax- 


Increased. 

Somewhat  diminished. 

Diminished  a  little. 

Somewhat  irregular. 

Nearly  normal. 

As  in  obstruction,  but  there 

is   more    tendency   to 

dropsy. 


178 


DIFFERENTIAL   DIAGNOSIS. 


DIFFERENTIAL  SIGNS  BETWEEN  PULMONARY  OBSTRUCTION 
AND  TRICUSPID  REGURGITATION. 


PULMONARY    OBSTRUCTION. 


Systolic,    on  ward,    ventri-  Murmur, 
culo-pulmonary. 

Left  border  of  sternum,  in 
second  interspace. 

Generally  anaemia.  Some- 
times pressure  of  solidi- 
fied lung  (phthisical  or 
pneumonic)  upon  the 
artery.  Rarely  organic, 
and  then  usually  con- 
genital. 

Frequently  Bruit  de  diable 
in  the  jugular  veins. 


Point  of  greatest 
intensity. 

Cause. 


Associated  Signs. 


TRICUSPID    REGURGITATION. 


Systolic,    backward,   ven- 
triculo-auricular. 

Base  of  ensiform  cartilage. 


Generally  secondary  to  dis- 
ease of  the  lung:  or  of 
left  side  of  the  heart. 


Systolic   pulsation   of   the 
distended  jugular  veins. 


Endocardial  murmurs  can  be  distinguished  from  pericardial  by  atten- 
tion to  the  following  physical  signs : — 


PERICARDITIS. 


1st  Stage. 

Inflammation 
without  effu- 


sion). 


SYMPTOMS. 


If  occurring  during 
the  course  of  acute 
rheumatism  the  dis- 


ease 


come  on 


may 
insidiously. 
Pain  and  tenderness 
in  the  cardiac  re- 
gion. Palpitation. 
Increased  frequency 
of  the  pulse.  Short- 
ness of  breath. 
Anxiety.     Pyrexia. 


PHYSICAL    SIGNS. 


Greater  extent  of  visible  impulse 
than  natural,  and  on  palpation 
the  impulse  is  found  to  be 
more  forcible,  but  unequal. 
Friction  fremitus  rare.  Area 
of  dullness  not  altered.  Single 
or  double  friction  sound,  often 
preceded  by  a  cantering  action 
of  the  heart.*  Heart  sounds 
may  be  unchanged  or  even 
louder  than  in  health,  or  they 
may  be  masked  by  the  fric- 
tion sounds. 


*  Cantering  action  of  the  heart,  beside  being  met  with  in  commencing  pericarditis, 
is  also  caused  by  reduplication  of  the  first  or  second  sound  of  the  heart  against  the 
thoracic  wall  at  the  moment  of  diastole,  generally  due  to  pericardial  adhesions. 


DISEASES    OF  THE    CIRCULATORY  APPARATUS. 


170 


PERICARDITIS— {Continued ). 


2d  Stage. 

(With    effu- 
sion). 


SYMPTOMS. 


3d  Stage. 

(Resolution). 


Less  pain.  Pulse 
small,  frequent,  and 
sometimes  irregu- 
lar. Dyspnoea  and 
often  orthopncea. 
Irritable  cough. 
Loss  of  voice.  Dys- 
phagia. Fullness  of 
veins  in  the  neck. 
Duskiness  of  com- 
plexion. Great 
anxiety.  Sleepless- 
ness.   Delirium. 


A  gradual  subsidence 
of  the  symptoms  of 
the  second  stage. 


PHYSICAL   SIGNS. 


Bulging  of  the  precordial  region. 
Impulse  displaced  upward 
and  outward ;  undulatory. 
On  palpation,  feeble  and  some- 
times not  perceptible;  irregu- 
lar. Area  of  cardiac  dullness 
increased,  first  noticed  at  the 
base  of  the  heart,  and  after- 
ward extending  to  left  of 
apex  beat,  increased  by  the 
recumbent  posture.  Heart 
sounds  feeble,  distant  and 
muffled  at  apex,  louder  and 
more  superficial  at  base.  Fric- 
tion may  or  may  not  be  heard. 

Diminution  of  the  dullness  from 
above  and  laterally.  Heart 
sounds  become  clearer.  Fric- 
tion sounds  may  be  heard  with 
increased  intensity. 


Post-mortem  Appearances. — 1st.  Pericardium  is  dry,  inflamed  and 
has  lost  its  polish.  Exudation  of  lymph  on  both  surfaces,  but  more  on 
the  visceral.     The  membrane  may  have  a  shaggy  appearance. 

2d.  Fluid  in  variable  quantity  in  the  sac  of  the  pericardium.  Usually 
sero-fibrinous,  containing  flocculi  of  lymph.  It  may  be  purulent  or  bloody. 

3d.  Organized  lymph  on  the  pericardium,  with  or  without  adhesions 
between  the  two  surfaces,  adherent  or  united  by  mesh-like  adhesions. 

The  Pain  of  Pericarditis. — Rheumatic  pericarditis  is  more  or  less 
painful ;  but  secondary  pericarditis  developing  in  the  acute  stage  of  in- 
fectious or  the  chronic  period  of  cachectic  diseases,  is  invariably  painless. 

Peripheric  pain  nearly  equal  on  both  sides  of  the  chest ;  or  remaining 
localized  at  the  precordial  region,  at  the  epigastrium,  or  at  the  left  side  of 
the  xyphoid  cartilage,  does  not  increase  the  danger  of  the  pericarditis.  But 
if  central,  giving  rise  to  disturbance  of  circulation  and  respiration,  and 
simulating  that  of  angina  pectoris,  it  means  acute  inflammation  of  the 
cardiac  nerves,  and  marks  an  exceptionally  bad  case  of  pericarditis.  (Dr. 
Wertheimer,  "These  de  Paris,"  1876 ;  Dobell's  Reports.) 


ISO 


DIFFERENTIAL    IMAGXosiS. 


DIAGNOSIS  BETWEEN  ACUTE  ENDOCARDIAL  AND  EXOCARDIAL 
(PERICARDIAL)  SOUNDS. 

The  sounds  respectively  perceptible  in  endocarditis  and  pericarditis  and 
allied  disorders,  may  he  discriminated  by  the  following  table: — 

ENDOCARDIAL. 

1.  A  blowing  sound,  soft  and 
bellows-like;  not  affected  by  pres- 
sure. 


2.  A  thrill  may  be  felt  on  palpa- 
tion. 

3.  The  sound  appears  distant. 

4.  May  exist  only  with  the  sys- 
tole or  the  diastole. 

5.  Accompanies  the  heart  sounds. 

6.  Heard  along  the  course  of  the 
great  vessels,  or  conducted  round  to 
the  back 

7.  Persistent  character. 


8.  Area  of  cardiac  dullness  not 
altered. 


1.  A  creaking, 
to-and-fro 


EXOC  LRDIAL. 

rubbing,  rough, 
sound,    intensified     by 
pressure  of  the  stethoscope  and  by 
the  patient  bending  forward. 

2.  On  palpation  friction  fremitus 
may  be  felt. 

3.  The  sound  appears  near. 

4.  Exists  with  diastole  as  well  as 
systole. 

5.  Does  not  correspond  with  the 
rhythm  of  the  heart. 

6.  Confined  to  the  region  of  the 
heart  and  limited  to  site  of  produc- 
tion. 

7.  Rapid  and  frequent  change  in 
character;  here  to-day  and  gone  to- 
morrow. 

8.  Increased  area  of  dullness,  if 
fluid  be  also  present. 

DIFFERENTIAL  SIGNS  OF  CARDIAC  DILATATION  AND  PERICARDITIS 

WITH  EFFUSION. 


CARDIAC   DILATATION. 

Dullness  increased   in  the   hori- 
zontal axis,  of  a  square  outline. 

Heart  sounds  feeble  but  clear. 

Transition  from  dullness  to  lung 
resonance  more  gradual 
No  friction  sound. 
Limits  of  dullness  persistent. 

Apex  beat  felt  at  lower  limits  of 
cardiac  dullness. 


PERICARDITIS    WITH    EFFUSION. 

Precordial  dullness  extends  up- 
ward and  is  of  a  rounded  pyramidal 
outline,  with  apex  above. 

Heart  sounds  feeble,  and  distant 
sounding. 

Transition  from  dullness  to  luug 
resonance  abrupt. 

Occasionally  friction  sound. 

Limits  of  dullness  often  vary 
from  day  to  day  or  week  to  week. 

Apex  beat  some  distance  above 
lower  limit  of  cardiac  dullness. 
(Sansom). 


DISEASES    OF   THE    CIRCULATORY   APPARATUS. 


181 


There  is  no  doubt  but  that  the  general  rules  laid  down  for  diagnosing 
pericardial  effusion  have  been  too  vague.  Dr.  T.  M.  Rotch,  of  Boston, 
has  lately  re-examined  the  subject,  and  succeeded  in  fixing  a  more  perfect 
diagnostic  sign  than  any  hitherto  mentioned.  He  shows  that  an  area  of 
flatness  at  from  two  to  three  centimeters  from  the  right  edge  of  the  sternum 
in  the  fifth  intercostal  space  is  almost  absolutely  sufficient  to  mark  the 
presence  of  an  effusion,  and  differentiate  it  from  enlarged  heart.* 

DIFFERENTIAL  SIGNS  OF  HYPERTROPHY  AND  DILATATION. 


Palpation. 


Percussion. 


Auscultation. 


Pulse. 

General 
symptoms. 


SIMPLE  IIYPERTKOPIIY. 


Cardiac  area  extend- 
ed. Impulse  strong, 
lifting,  or  forcing. 


Dullness  increased 
laterally  and  down- 
ward. 

First  sound  dull,  pro- 
longed, intensified ; 
second  sound  inten- 
sified. No  respira- 
tory murmur  over 
prsecordium 

Strong,    full,    ] 
pressible. 

Fullness  in  the  head, 
epigastric  weight, 
short  breath,  rarely 
debility ; 
disease. 


HYPERTROPHY 
WITH   DILATATION. 


Extent  of  visible 
impulse  great- 
1  y  increased. 
Action  regu- 
lar, strong. 

Dullness  lateral 
and  down- 
ward. 

Both  sounds  pro- 
longed. 


Less  strong,  vari- 
able. 


Bright's 


SIMPLE   DILATATION. 


Extent  of  impulse 
greatly  increased, 
but  feeble,  without 
lifting  or  forcing 
character. 

Dullness  increased 
in  the  horizontal 
axis  of  the  heart. 

Both  sounds  short, 
abrupt  and  feeble. 
Feeble  respiratory 
murmur. 


Weak,  compressi- 
ble, irregular. 

Dyspnoea,  cough, 
palpitation,  portal 
congestion,  debil- 
ity, ascites. 


FATTY  DEGENERATION  OF  THE  HEART. 

This  condition  of  the  heart  is  frequently  associated  with  dilatation. 
Generally  the  area  of  precordial  dullness  is  normal  or  slightly  increased ; 
the  impulse  weak;  the  apex  beat  indistinct;  the  action  irregular;  the  first 

*  "  Medical  Communications  of  the  Massachusetts  Medical  Society."     1878. 


182  DIFFERENTIAL   DIAGNOSIS. 

sound  short  and  feeble;  the  second  prolonged  and   intensified;  pulse  is 
irregular. 

These  physical  signs  obviously  offer  very  little  ground  for  a  diagnosis. 
Of  rational  signs  the  following  have  been  mentioned: — 

1.  Attacks  of  faintness  attended  with  sensations  of  great  coldness,  re- 
curring without  obvious  cause.  (Da  Costa). 

2.  A  re  us  senilis.  For  this  to  be  significant  of  cardiac  degeneration, 
the  riug  must  be  ill-defined,  rather  yellowish  than  white,  and  the  rest  of 
the  cornea  be  slightly  cloudy  or  opaque,  not  clear  and  translucent,  a  tinge 
of  jaundice  being  present.  When  this  is  the  case,  "the  chances  of  cardiac 
degeneration  are  formidable"  (Sansom). 

3.  Paroxysms  of  severe  pain  across  the  upper  part  of  the  sternum,  and 
in  the  region  of  the  heart. 

4.  Stomach  derangements,  accompanied  sometimes  by  constipation,  but 
more  generally  by  diarrhoea  and  frequent  vomiting.  This  Dr.  L.  H.  J. 
ITayne  thinks  "  almost  pathognomonic  of  this  disease."  (Lancet,  January, 
1875.) 

5.  The  "Cheyne-Stokes"  Respiration  of  ascending  and  descending 
rhythm  is  present  in  about  one-third  of  the  cases,  and  is  probably  de- 
pendent on  atheroma  of  the  aorta  (Hayden).  This  symptom  was  first 
described  in  a  case  by  Dr.  Cheyne,  in  1818,  as  follows: — 

"For  several  days  his  breathing  was  irregular;  it  would  entirely  cease 
for  a  quarter  of  a  minute;  then  it  would  become  perceptible,  though  very 
slow;  then,  by  degrees,  it  became  heaving  and  quick;  and  then  it  would 
gradually  cease  again.  This  revolution  in  the  state  of  breathing  occupied 
about  a  minute,  during  which  there  were  about  thirty  acts  of  respira- 
tion." In  this  case  fatty  disease  of  the  heart  was  very  marked,  while  the 
valves  were  healthy,  and  the  aorta  was  "studded  with  steatomatous  and 
earthy  concretions." 

No  general  attention,  however,  was  directed  to  the  peculiarity  and 
striking  character  of  this  symptom,  until,  in  1846,  Dr.  Stokes  urged  its 
significance  as  a  sign  of  fatty  degeneration  of  the  heart,  believing  that  its 
presence  was  pathognomonic  of  this  affection,  and  that  it  always  betok- 
ened a  fatal  and  not  far  distant  termination.  That  it  did  not  necessarily 
depend  on  fatty  degeneration  of  the  heart  itself,  was  soon  shown  by  Dr. 
Seaton  Reid,  who  described  a  case  in  which  the  muscular  structure  was 


DISEASES   OF  THE   CIRCULATORY   APPARATUS.  1  83 

healthy,  while  the  mitral  and  aortic  valves  were  both  incompetent,  the 
left  ventricle  was  hypcrtrophied,  and  the  aorta  dilated  and  atheromatous. 
It  remains  an  important  and  significant,  if  not  pathognomonic  sign. 

Dr.  Hayden  is  of  opinion  that  the  absence  of  the  impulse,  or  its  ex- 
tremely feeble  character;  the  brief  duration  of  the  first  sound,  whether 
marked  or  sharp,  in  primary  cases,  and  its  almost  complete  or  absolute 
extinction  in  those  preceded  by  hypertrophy ;  the  restriction  of  the  sounds 
within  a  very  limited  area;  and  the  occasional  irregularity  of  the  heart's 
action,  will  suffice,  in  the  majority  of  cases,  to  establish  the  diagnosis  of 
fatty  heart  from  the  physical  signs  alone.  He  adds  that  the  incipiency 
of  primary  fatty  degeneration  may  be  suspected,  if  the  pulse,  previously 
regular,  becomes  weak  and  irregular;  if  the  surface  be  pale,  the  patient 
subject  to  dizziness  or  syncope,  and  the  cardiac  impulse  feeble;  although 
the  sounds  of  the  heart  may  not  appreciably  differ  from  their  normal 
character. 

A  slow  pulse  sometimes  is  associated  with  fatty  heart ;  but  it  also  occurs 
as  a  result  of  disorders  of  the  vagus  nerve,  following  diphtheria ;  or  after 
an  attack  of  malarial  fever;  or  after  the  administration  of  certain  drugs, 
such  as  digitalis  or  aconite.  In  all  cases  it  is  necessary  to  exclude  a  slow 
pulse  which  is  natural  and  peculiar  to  the  patient.  Irregular  or  slow 
pulse  due  to  adherent  pericardium  may  be  distinguished  by  the  history 
and  physical  signs. 


184  DIFFERENTIAL   DIAGNOSIS. 

CHAPTER  IV. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  Stoma <  n  and  Bowels. — Principal  Symptoms — The  Tongue — The 
Appetite — Acidity  (I)  from  Fermentation,  (2)  from  Hypersecretion — 
Pain — Flatulence — Vertigo,  (1)  Stomachal,  (2)  Cerebral — Vomiting, 
(1)  Stomachal,  (2)  Cerebral — Comparison  of  Atonic  Dyspepsia,  Chronic 
Gastritis,  Gastric  Ulcer  and  Gastric  Cancer — Indigestion  or  Dyspep- 
sia— Abdominal  PJdhisis — Obstruction  of  the  JBoivels,  Enteritis  and 
Colitis. 

The  Liver. — Method  of  Examination — Significance  of  Pain  in  the 
Liver — Significance  of  Jaundice — Jaundice  with  Obstruction — Jaundice 
without  Obstruction  —  Diseases  Characterized  by  Enlargement  with 
Smooth  Surface ;  Enlargement  ivith  Uneven  Surface ;  with  Diminution 
of  the  Organ — Hepatic  Abscess. 

Internal  Parasites.  —  Tape-worm — Hydatids  —  Round  Worms — 
Thread  Worms —  Trichinosis. 

The  principal  symptoms  to  which  the  attention  is  directed  in  the  diag- 
nosis of  diseases  of  the  digestive  organs  are  those  connected  with  the 
tongue,  the  appetite,  pyrosis,  vomiting,  flatulence,  vertigo  and  pain. 

THE  TONGUE. 

Late  writers  have  shown  considerable  skepticism  on  the  accuracy  of 
the  appearance  of  the  tongue  as  indicative  of  the  condition  of  the  lining 
membrane  of  the  stomach.  It  is  true  that  a  white  and  furred  or  a  red 
and  cracked  tongue  is  occasionally  seen  in  healthy  subjects;  but  the 
standard  of  comparison  should  not  be  an  ideally  cleau  tongue,  but  the 
condition  of  the  organ  in  the  patient  under  inspection  when  in  health. 
Local  causes,  such  as  carious  teeth  and  irritating  agents  (tobacco,  tea, 
mercury,  etc.),  must  be  allowed  for  in  the  examination.  When  these  and 
similar  considerations  are  weighed  together  with  the  repeated  instances  of 
simultaneous  affections  of  the  stomach  and  tongue  revealed  by  post-mor- 
tems, no  question  remains  that  the  appearance  and  state  of  the  latter 
organ  often  is  of  high  diagnostic  worth. 


DISEASES   OP   THE    DIGESTIVE   SYSTEM.  185 

Dr.  Robert  Farquitarson  states,  in  a  recent  lecture  on  the  diagnosis 
of  dyspepsia,*  that  in  his  experience  the  class  of  tongue  which  coincides 
most  commonly  with  digestive  disturbance  is  that  in  which  the  tongue 
seems  to  be  covered  with  a  thin,  white  fur,  which  on  minute  inspection 
is  seen  to  be  composed  of  a  series  of  minute  raised  dots,  and  this  usually 
coincides  with  pain  immediately  following  meals. 

If  the  tongue  is  raw  and  quite  stripped  of  epithelium,  with  enlarged 
and  prominent  papillae,  as  we  often  see  in  phthisis,  pain  immediately  after 
food  and  vomiting  are  usual  symptoms,  or  large,  red  papillae  may  stand 
in  bold  relief  through  a  pale  coating,  or  the  tongue  may  be  simply  large 
and  pale  and  flabby,  as  though  too  big  for  the  mouth. 

Dr.  Wilson  Fox  specifies  the  following  conditions  of  the  tongue  as 
valuable  aids  to  diagnosis  in  this  class  of  diseases : — 

Dyspepsia  with  distinct  atony  of  the  stomach.  The  tongue  broad,  pale, 
and  flabby,  the  papillae  generally  enlarged,  more  especially  on  the  tip  and 
edges. 

Dyspepsia  from  irritative  causes.  The  tongue  is  redder  than  usual, 
often  of  a  bright  florid  color,  or  even  raw  looking.  It  is  often  pointed 
at  the  tip,  which,  together  with  the  sides,  presents  an  extreme  degree  of 
injection,  the  papillae  standing  out  as  vivid  red  points.  This  form  is 
often  associated  with  aphthae,  and  is  most  common  in  scrofulous  children 
and  phthisical  adults. 

Dyspepsia  from  excessive  or  hurried  eating  is  apt  to  present  a  tongue 
uniformly  covered  throughout  the  greater  part  of  its  surface  with  a  thick 
fur,  whitish  or  brownish,  with  some  degree  of  enlargement  and  redness 
of  the  papillae  at  the  tip  and  edges. 

Neuroses  of  the  stomach  display  a  tongue  which,  as  a  rule,  is  clean, 
though  often  pale,  broad  and  flabby. 

THE  APPETITE. 

Anorexia,  or  loss  of  appetite,  is  observed  in  cancer,  in  most  inflamma- 
tory states  of  the  stomach,  in  obstinate  constipation,  as  well  as  in  the 
pyrexial  state. 

Boulimia,  or  excessive  appetite,  is  found  associated  with  enlargement  of 
the  stomach,  induration  of  its  coats,  also  in  diabetes  and  various  forms 
of  mental  alienation. 

*  Medical  Press  and  Circular,  July,  1877. 


186 


DIFFERENTIAL    IUAONOSIS. 


(  hpridous  and  depraved  appetite  is  met  with  in  sufferers  from  intes- 
tinal worms,  in  some  cases  of  chronic  inflammation  of  the  stomach,  as 
well  as  in  chlorosis,  pregnancy  and  hysteria. 

ACIDITY  OF  THE  STOMACH,  (1)  FROM  FERMENTATION, 
(2)  FROM  HYPER-SECRETION. 

Acidity  of  the  stomach,  pyrosis,  heartburn,  and  water-brash,  are  dis- 
turbances of  the  digestion  frequently  included  in  one  category.  In  all, 
an  excessive  amount  of  acid  is  formed  in  the  stomach;  but  in  some  cases 
the  origin  of  the  acid  is  to  be  sought  in  fermentative  action,  and  in  others 
in  hypersecretion  from  the  coats  of  the  stomach,  thus  calling  for  different 
lines  of  treatment. 

The  following  differential  table,  based  on  one  given  by  Dr.  Wilson 
Fox,  exhibits  in  a  concise  form  the  distinction  between  the  two  forms  of 
acidity: — 


ACIDITY  FROM  FERMENTA- 
TION. 

Occurs  in  connection  with  causes 
which  impede  digestion. 


Usually  attains  its  height  some 
hours  after  food,  and  is  more  marked 
in  proportion  to  the  size  of  the 
meal,  and  inversely  to  the  digestive 
powers. 

Flatulence  is  common. 

Pain  not  severe,  and  but  slightly 
or  not  at  all  relieved  by  eating. 

Vomiting  is  rare. 
Vomited  matters  may  contain  or- 
ganic acids,  torulre  and  sarcinse. 

Urine  frequently  shows  an  alka- 
1  escent  reaction. 


ACIDITY  FROM  HYPER-SECRE- 
TION. 

Is  most  common  as  a  reflex  symp- 
tom, or  in  connection  with  other 
nervous  disturbance,  or  with  ulcer 
and  cancer  of  the  stomach. 

Occurs  in  the  empty  stomach,  or 
rapidly  after  food,  and  is  often  of 
great  intensity  after  a  small  meal. 


Flatulence  is  rare. 

Pain  more  severe,  most  felt  when 
the  stomach  is  empty,  and  is  relieved 
by  food. 

Vomiting  is  common. 

Vomited  matters  apt  to  show 
hydrochloric  acid  in  excess. 

Urine  rarely  alkaline. 


DISEASES    OF  THE    DIGESTIVE  SYSTEM.  187 

In  both  forms  the  process  of  digestion  is  impaired,  hut  to  a  more 
marked  degree  in  the  fermentative  variety,  in  which  also,  as  a  natural 
consequence,  the  impairment  of  nutrition  of  the  patient  is  more  obvious. 
As  the  fermentative  action  interferes  with  the  functions  of  the  liver,  the 
stools  are  apt  to  be  pale,  and  the  patient  suffer  from  constipation.  The 
frequency  with  which  attacks  of  gout  and  rheumatism  are  preceded 
by  this  form  of  acidity  points  to  a  diathetic  process  involving  the  general 
constitution. 

PAIN. 

Pain  in  the  stomach  is  indicative  of  one  of  the  following  conditions : — 

1.  The  presence  of  irritating  foreign  bodies,  as  mechanical  substances, 
corrosive  poisons,  blood  or  bile  in  large  quantities,  inflation  from  air  or 
gases,  etc. 

2.  Organic  diseases  altering  the  anatomical  structure  of  the  coats, 
especially  gastritis,  chronic  ulcer,  cancer  and  thickening  of  the  pylorus. 

3.  Perverted  secretions,  as  in  acidity. 

4.  Perverted  innervation,  which  may  be  a  local  neurosis,  as  in  forms 
of  dyspepsia  where  pain  is  the  prominent  symptom,  or  as  in  cramp  of  the 
muscles  of  the  stomach;  or  it  may  be  from  general  disorders,  as  in 
patients  of  a  rheumatic  or  gouty  diathesis ;  or  it  may  be  referable  to  the 
general  nervous  system,  as  in  pure  neuralgia  of  the  stomach  and  hysteria. 

Pain  in  the  stomach  must  be  distinguished  from  rheumatic  and  other 
pains  in  the  abdominal  muscles  immediately  over  the  stomach.  In  the 
latter  the  superficial  tenderness  is  much  greater;  it  is  usually  more  marked 
in  the  left  recti  and  obliqui  abdominis  muscles,  and  especially  near  their 
attachment  to  the  ribs,  where  moderate  pressure  cannot  affect  the  stomach, 
and  by  its  independence  of  the  digestive  acts   (Bricquet). 

Pain  in  the  stomach  is  also  liable  to  be  simulated  by  pain  in  the  course 
of  the  transverse  colon,  especially  when  the  colon  is  distended  with  gas. 
The  diagnosis  may  usually  be  made  by  gentle  percussion,  the  note  arising 
from  tapping  a  distended  colon  being  less  prolonged  and  of  a  higher  pitch 
than  that  elicited  from  the  stomach.  The  pain  from  the  colon  is  also  less 
felt  at  the  ensiform  cartilage  than  in  the  hypochondriac  regions,  and  often 
extends  toward  the  sigmoid  flexure,  and  is  associated  with  other  signs  of 
intestinal  flatulence. 

Pain  in  the  stomach  depending  on  diseases  of  the  spinal  cord  is  dis- 


188  DIFFERENTIAL   DIAGNOSIS. 

tinguished  by  its  superficial  tenderness,  by  the  presence  of  other  painful 
points  in  the  affected  nerve,  and  by  the  co-existence  of  other  nervous,  and 
the  absence  of  digestive  symptoms. 

FLATULENCE  AND  ERUCTATION. 

Dyspeptics  generally  suffer  from  gases  in  the  stomach,  producing  eruc- 
tations. These  gases  are  either  generated  from  imperfectly  digested  food 
or  are  secreted  from  the  capillaries. 

Eructations  having  the  taste  or  odor  of  spoiled  eggs,  and  occurring 
during  the  process  of  digestion,  indicate  the  presence  of  sulphuretted  hy- 
drogen, from  the  decomposition  of  food. 

When  the  eructations  are  odorless,  and  occur  chiefly  in  an  empty  state 
of  the  stomach,  they  indicate  a  gaseous  secretion  of  carbonic  acid,  hy- 
drogen or  nitrogen  from  the  coats  of  the  capillaries. 

In  the  former  case  the  indications  are  to  use  anti-ferments;  while  in 
the  latter  relief  is  often  attained  by  simply  regulating  the  hours  of  meals, 
so  as  to  avoid  long  intervals  between  the  times  of  taking  food. 

VERTIGO.  (VERTIGO  E  STOMACHO  LGESO.) 
Stomachal  vertigo  is  not  uufrequently  difficult  to  distinguish  as  such, 
because  in  all  severe  vertigoes  the  stomach  is  disturbed.  In  undoubted 
examples  the  vertigo  always  bears  some  distinct  relation  to  the  condition 
of  the  stomach,  coming  on  only  when  that  organ  is  full,  or  only  when  it 
is  empty,  or  only  after  certain  articles  of  food,  as  shell-fish,  strawberries, 
coffee,  fresh  bread,  etc.  There  are  also  generally  some  dyspeptic  symp- 
toms other  than  vertigo  complained  of.  Some  other  points  are  mentioned 
in  the  following  table: — 

STOMACHAL  VERTIGO.  CEREBRAL  VERTIGO. 

Usually  appears   in   definite  re-|      Occurs   without   relation   to   the 
lation  to  taking  food;  either  after  a 
meal,  after  particular  ingesta,  or  on 
an  empty  stomach. 

Generally  occurs  in  middle  life. 

The  apparent  motion  is  felt  to  be 
subjective,  not  real  (Gowers). 

Special  senses  not  involved  be- 
yond perverted  vision.  Conscious- 
ness never  lost. 


taking. 


Occurs  in  advanced  life. 

A  sense  of  movement  or  actual 
turning  of  objects. 

Deafness  and  tinnitus  aurium 
often  present.  Sometimes  loss  of 
consciousness. 


DISEASES    OF  THE   DIGESTIVE  SYSTEM.  189 

VOMITING,  (1)  FROM  DISEASE  OF  THE  STOMACH, 
(2)  FROM  DISEASES  OF  THE  BRAIN. 

Persistent  vomiting  is  a  frequent  symptom  of  obstinate  gastric  disturb- 
ance; and  it  has  also  been  frequently  noted  as  a  symptom  associated  with 
organic  diseases  of  the  brain  and  cord,  not  unfrequently  masking  them 
and  diverting  the  attention  of  the  practitioner  from  the  real  seat  of  lesion. 
Thus  in  suddenly  induced  cerebral  anaemia,  in  the  commencement  of  the 
paralysis  which  follows  diphtheria,  in  tubercular  meningitis,  in  concus- 
sion of  the  brain,  in  poisoning  affecting  the  brain  and  cord,  and  in  fact  in 
almost  any  disease  of  the  cerebral  centres,  but  especially  the  meninges, 
it  is  possible  that  one  of  the  earlier  and  prominent  symptoms  will  be 
obstinate  vomiting. 

A  comparison  of  the  leading  clinical  features  of  these  two  forms  shows 
that  they  may  be  readily  distinguished. 

In  a  general  way  it  may  be  stated  that  vomiting  arising  from  the 
stomach  is  attended  with  more  or  less  pain,  with  a  furred  tongue,  with 
constipation  or  diarrhoea,  sense  of  weight  at  the  epigastrium,  and  pre- 
ceded for  a  considerable  period  by  a  sense  of  nausea. 

Vomiting  from  cerebral  causes,  on  the  other  hand,  is  usually  character- 
ized by  an  absence  of  these  symptoms,  by  a  clean  tongue  and  a  history  of 
freedom  from  digestive  disturbance. 

Dr.  Romberg  has  given  the  following  criteria  for  its  discrimination 
when  the  vomiting  is  of  cerebral  origin  : — 

1.  The  influence  of  the  position  of  the  head ;  the  vomiting  is  arrested 
in  the  horizontal,  and  recurs  and  is  frequently  repeated  in  the  erect 
position. 

2.  The  prevailing  absence  of  premonitory  nausea. 

3.  The  peculiar  character  of  the  act  of  vomiting ;  the  contents  of  the 
stomach  are  ejected  without  fatigue  or  retching,  as  the  milk  is  rejected  by 
babies  at  the  breast. 

4.  The  complication  with  other  phenomena,  the  more  frequent  of  which 
are  pains  in  the  head,  and  irregularity  of  the  cardiac  and  radial  pulse, 
increased  during  and  subsequent  to  the  act  of  vomiting. 

The  following  differential  table  further  exhibits  the  points  of  contrast 
(from  Dr.  W.  Fox) :— 


190 


DIFFERENTIAL    V>I  At ;  N<  (SIS. 


GASTRIC  VOMITING. 

Epigastric  pain  and  tenderness 
are  common,  and  in  some  cases  very 
marked. 

Nausea  is  constant. 

Oppression  and  weight  at  the 
epigastrium  are  constant. 

Bowels  are  variable. 

The  tongue  is  loaded,  except  in 
certain  cases  of  cancer  or  ulcer. 


Headache  is  absent,  or  not  in- 
tense, chiefly  frontal,  of  gradual  in- 
vasion, and  relieved  by  vomiting. 

Vertigo  is  rare  and  relieved  by 

vomiting. 

Other  nervous  phenomena  are 
rarely  present,  and  then  only  in 
slighter  forms,  and  relieved  by 
vomiting. 


CEREBRAL  VOMITING. 

Epigastric   pain    and    tenderness 
are  rare. 

Nausea  is  frequently  absent. 
These  are  rare. 

Bowels  are  constipated. 
The  tongue  is  usually  clean. 


Headache  often  violent,  the  inva- 
sion sudden,  and  not  relieved  by 
vomiting. 

Vertigo  is  very  frequent  and  not 
relieved  by  vomiting. 

Indistinctness  of  vision  and  diplo- 
pia. Confusion  of  ideas.  Loss  of 
memory.  Not  relieved  by  vomiting. 
Anaesthesia  or  paresthesia,  paralysis 
or  cramp,  convulsion  or  coma,  are 
common  or  soon  supervene. 

The  indications  derived  from  the  nature  of  the  matters  thrown  up  in 
vomiting  are  as  follows : — 

Ingesta.  The  food  is  returned  unaltered,  or  but  slightly  changed,  in 
nervous  vomiting ;  in  a  half  digested  state  and  strongly  acid  in  chronic 
inflammation  and  cancer  of  the  stomach;  mixed  with  the  microscopic 
forms  known  as  sarcinse  and  torulse  in  chronic  gastritis,  gastric  ulcer  and 
cancer. 

JTucus  is  vomited  in  a  catarrhal  or  sub-inflammatory  condition  of  the 
stomach. 

Bile  appears  whenever  the  retching  is  long  and  violent,  and  does  not 
indicate  any  special  disease. 

Pus  is  not  formed  in  the  stomach,  and  when  present  in  the  vomit  in- 
dicates disease  in  the  cesojjhagus. 

Fceces  also  indicates  a  disease  elsewhere  than  the  stomach,  usually  an 
obstruction  of  the  intestinal  canal. 

Blood  is  thrown  up  in  gastric  cancer  and  ulcer,  in  severe  gastritis,  in  ex- 


DISEASES   OP   THE    DIGESTIVE    SYSTEM.  191 

ternal  injuries,  vicariously  (of  the  uterus),  and  frequently  from  disease  of 
the  heart  or  liver,  producing  distention  of  the  capillaries.  The  presence 
of  blood  directly  proceeding  from  the  stomach,  says  Dr.  Fox,  if  accom- 
panied by  severe  pain,  is  almost  pathognomonic  of  either  gastric  ulcer  or 
cancer. 

ATONIC  DYSPEPSIA,  INFLAMMATORY  DYSPEPSIA, 
GASTRIC  ULCER,  GASTRIC  CANCER. 

The  chief  points  in  the  diagnosis  of  diseases  of  the  stomach  are  those 
connected  with  the  differentiation  of  simple  dyspepsia  (atony  of  the 
stomach),  inflammatory  dyspepsia  (gastritis,  gastric  catarrh,  catarrhal  in- 
flammation of  the  stomach),  gastric  ulcer  and  gastric  cancer. 

From  this  group  the  nervous  disturbances  of  the  stomach  are  broadly 
marked  off  by  the  superficial  character  of  the  pain  in  these  latter,  its 
independence  of  the  acts  of  digestion  and  the  nature  of  the  food,  the  co- 
existence of  other  neuralgise,  the  frequent  absence  of  emaciation  and  other 
disturbances  of  nutrition,  and  the  sex  and  age  of  the  patients. 

In  reference  to  the  value  of  percussion  in  diagnosing  gastric  cancer, 
Professor  Peter,  of  Paris,  has  directed  attention  to  the  fact  that  when 
superficial  percussion,  percussion  en  dedolant,  is  made  over  the  stomachal 
region  somewhat  distended  by  gas,  there  is  found  at  certain  points, 
especially  in  the  region  of  the  greater  curvature,  a  certain  obscurity  of 
the  note  alternating  with  the  zones  of  sonority.  But  this  sign  is  abso- 
lutely wanting  on  deep  percussion  such  as  is  ordinarily  employed.  Prof. 
Peter,  by  this  means,  diagnosed  a  cancer  of  the  stomach  situated  at  the 
posterior  surface  of  the  greater  curvature,  with  some  cancerous  nodules 
probably  disseminated  through  the  epiploon  below  the  splenic  region  and 
also  in  the  hypogastric  region.  At  this  last  point  also  superficial  percus- 
sion gave  the  same  results. 

An  early  sign  of  gastric  cancer  is  the  presence  of  enlarged  glands  in 
the  skin  of  the  navel  (Maunder).  To  ascertain  the  mobility  and  outline 
of  the  stomach,  the  patient  may  be  desired  to  drink  one  or  two  tumblers 
of  soda  water.  This  distends  the  stomach  and  makes  the  tumor  prominent. 

The  following  comparative  table,  drawn  from  the  works  of  Drs.  W. 
Fox,  William  Brinton  and  Da  Costa,  illustrates  the  main  points  of 
difference  in  the  four  diseases  named : — 


192 


DIFFERENTIAL    DIAGNOSIS. 


ATONIC  DYSPEPSIA. 

No  pain  or  soreness  at  the  epigas- 
trium. Sensation  of  weight  or  load, 
rather  than  tenderness. 


Symptoms  of  indigestion.  Appe- 
tite impaired.  Thirst  generally  ab- 
sent.    Tongue  pale  and  flabby. 

Vomiting  rare. 


CHRONIC  GASTRITIS. 

Pain  at  the  epigastrium  somewhat 
augmented  by  food  ;  also  soreness. 
Both  constant,  though  not  severe. 


No  hemorrhage. 


Bowels  may  be  regular. 


Indigestion  present.  Appetite 
capricious.  Thirst  increased.  Tongue 
furred  and  red  at  edges. 

Sometimes  vomiting. 


Hemorrhage  absent,  or  rare  and 
trifling. 


No  febrile  symptoms. 

Nutrition    not  materially   inter- 
fered with. 

Not  confined  to  any  age. 


Course  of  disease  uniform ;  may 
be  cured. 


No  tumor.     Percussion  resonant. 


Bowels  constipated. 


Occasional  slight  pyrexia  (Fox). 

Slight  emaciation ;  slightly  earthy 
tint  to  skin  (Fox). 

More  common  in  middle  or  ad- 
vanced life. 


Disease  with  marked  exacerba- 
tions and  remissions.  May  be  re- 
lieved or  cured. 

No  tumor.     Percussion  resonant. 


DISEASES    OF   THE    DKJ I0STIVE   SYSTEM. 


1 93 


GASTRIC  ULCER. 

Pain  at  the  epigastrium  much 
augmented  by  food;  is  intermittent; 
subsides  after  digestion ;  pain  in  pa- 
roxysms, but  not  lancinating;  epi- 
gastric soreness  strictly  localized. 
Sometimes  a  painful  spot  over  lower 
dorsal  vertebra. 

Symptoms  of  indigestion  slight. 


Vomiting  may  be  present  or  not. 
Usually  relieves  the  pain. 

Abundant  hsematemesis. 


Bowels  slightly  or  not  consti- 
pated. 

No  fever  present. 

Frequently  extreme  pallor  and 
debility. 

May  occur  in  middle-aged  per- 
sons, but  is  frequently  seen  in  young 
adults,  especially  females. 

Duration  uncertain ;  may  get  well; 
may  run  on  rapidly  to  perforation  ; 
or  may  last  for  years. 

No  tumor.     Percussion  resonant. 


GASTRIC  CANCER. 


Pain  paroxysmal,  radiating,  often 
severe  and  lancinating;  rarely  re- 
mitting; never  intermitting;  little 
or  not  at  all  affected  by  food ;  not 
always  accompanied  by  soreness. 


Symptoms  of  indigestion  more 
marked.  Extreme  acidity  of  the 
stomach. 

Vomiting  a  very  frequent  symp- 
tom.    Does  not  relieve  the  pain. 

Hsematemesis  not  very  abundant; 
but  occasioning  frequently  vomiting 
of  a  substance  resembling  coffee 
grounds. 

Constipation  obstinate. 


Fever  not  uncommon. 

Gradual  and  progressive  loss  of 
flesh  and  debility. 

Most  common  in  elderly  people ; 
rarely  occurs  in  persons  under  forty 
years  of  age. 


Duration  about  one  year;  very 
rarely  reaches  two.  Termination 
fatal. 

Generally  a  tumor.  Percussion 
variable. 


19-t  DIFFERENTIAL   DIAGNOSIS. 

INDIGESTION  AND  DYSPEPSIA. 

Although  the  distinction  is  not  generally  drawn  in  ordinary  language 
between  dyspepsia  and  indigestion,  it  should  not  be  forgotten  that  they 
arc  not  synonymous.  Dyspepsia  lias  reference  to  an  altered  condi- 
tion oi*  the  digestive  fluid,  its  deficiency  or  excess,  or  to  an  organic 
affection  of  the  muscular  walls  of  the  stomach,  which  has  for  its  result 
imperfect  or  difficult  chymification  of  the  food;  indigestion  merely 
expresses  a  disturbance  of  function,  and  refers  to  the  result  rather  than 
the  cause.  In  dyspepsia  the  peptic  glands  or  muscular  apparatus  of  the 
stomach  arc  defective,  in  indigestion  they  may  be  normal,  but  have  their 
functions  interfered  with  by  improper  and  unaccustomed  articles  of  food, 
or  by  reflex  influence  from  other  organs. 

The  symptoms  of  INDIGESTION  are  tabulated  by  Dr.  Murchison 
as  follows* : — 

1.  A  feeling  of  weight  and  fullness  at  the  epigastrium  and  in  the 
region  of  the  liver. 

2.  Flatulent  distention  of  the  stomach  and  bowels. 

3.  Heartburn  and  acid  eructations. 

4.  A  feeling  of  oppression,  and  often  of  weariness  and  aching  pains  in 
the  limbs,  or  of  insurmountable  sleepiness  after  meals. 

5.  A  furred  tongue,  which  is  often  indented  at  the  edges,  and  a  clammy, 
bitter,  metallic  taste  in  the  mouth,  especially  in  the  morning. 

6.  Appetite  often  good;  at  other  times  anorexia  and  nausea. 

7.  An  excessive  secretion  of  viscid  mucus  in  the  fauces,  and  at  the 
back  of  the  nose. 

8.  Constipation,  the  motions  being  scybalous,  sometimes  too  dark,  at 
others  too  light,  or  even  clay  colored.  Occasionally  attacks  of  diarrhoea, 
alternating  with  constipation,  especially  if  the  patient  be  intemperate  in 
the  use  of  alcohol. 

9.  In  some  patients  attacks  of  palpitation  of  the  heart,  or  irregularity 
or  intermission  of  the  pulse. 

10.  In  many  patients  occasional  attacks  of  frontal  headache. 

11.  In  many,  restlessness  at  night  and  bad  dreams. 

12.  In  some,  attacks  of  vertigo  and  dimness  of  sight,  often  induced  by 
particular  articles  of  diet. 

*  "Functional  Derangements  of  the  Liver."     London,  1874. 


DISEASES   OF   THE   DIGESTIVE   SYSTEM. 


]  95 


DYSPEPSIA  may  be  due  to  impaired  motion  as  well  as  to  deficient 

secretion.      The  following   table  will   give   the   distinctive    points   for 

diagnosis  :* 

1.  Dyspepsia  from 
impaired  motion. 
Constant  symptom,  generally 
soon  replaced  by  sense  of 
tension  accompanying 
ulency. 

Characteristic  symptom. 


Uneasiness  after  meals. 


Flatulence . 


Gastric  pain. 


Constipation , 


Treatment. 


lat- 


Infrequent,  but  occurs  occa- 
sionally, as  a  result  of  flatu- 
lence, and  is  peculiar  in 
kind. 


Almost     always 
symptom. 


a     marked 


Strychnia,  carbolic  acid,  thy- 
mol, charcoal. 


2.  Dyspepsia  from 
defective  secketioh. 

Not  infrequent,  but  commonly 
soon  merged  into  acute 
pain. 


Comparatively  infre quent; 
some  of  the  worst  cases,  in 
which  pain  after  food  and 
other  symptoms  are  particu- 
larly severe,  are  entirely 
free  from  flatus.  The  tend- 
ency is  to  lactic,  butyric, 
and  perhaps  other  forms  of 
fermentation,  in  which 
gases  are  not  evolved. 

Variously  described  as  sharp, 
shooting,  dull,  or  dragging, 
is  the  most  characteristic 
symptom  of  defective  secre- 
tion of  gastric  juice. 

Not  generally  present,  and 
the  bowels  are  in  many 
cases  relaxed. 

Diet,  tonics,  pepsin  acids, 
hygienic  treatment. 


Hyperperistalsis,  dyspepsia  of  fluids,  flaccid  stomach,  and  other  states 
remain  for  discussion. 

ABDOMINAL  PHTHISIS. 

Abdominal  phthisis  (tubercular  peritonitis)  in  its  acute  forms,  closely 
simulates  typhoid  fever.  There  are  febrile  symptoms  attended  with  re- 
missions, heat  and  dryness  of  the  surface,  pains  in  the  limbs,  drowsiness 
and  disordered  secretions,  and  diarrhoea.  It  differs  from  typhoid  in  these 
particulars  : — 

1.  The  pain  is  diffused  over  the  abdomen,  not  limited  to  the  csecal 
region. 

2.  There  are  no  red  spots  (with  rare  exceptions). 

3.  There  is  generally  tubercular  disease  in  other  organs. 

4.  The  temperature  has  not  the  morning  remissions  of  typhoid. 

*  Arthur  Leared.  "Dyspepsia."  British  Medical  Journal,  May,  1879.     p.  660. 


196  DIFFERENTIAL   DIAGNOSIS. 

OBSTRUCTION  OF   THE  BOWELS. 

The  causes  of  a  mechanical  stoppage  of  the  bowels  are  principally  the 

following-:   intussusception;   impaction  of  fsecesj    strictures;  twisting  of 
the  bowel  (volvulus);  hernia?;  pressure  of  tumors. 

The  symptom  first  noticed  is  constipation  with  colicky  pains,  which  do 
not  yield  to  ordinary  remedies;  slight  distention  of  the  abdomen  and 
some  soreness  on  pressure.  Vomiting  follows,  very  severe,  even  becom- 
ing fecal.  It  is  liable  to  be  confounded  with  peritonitis  and  strangulated 
hernia.  The  following  rules  for  diagnosis  have  been  laid  down  by  the 
eminent  surgeon,  Mr.  Jonathan  Hutchinson,  of  London  : — 

1.  When  a  child  becomes  suddenly  the  subject  of  symptoms  of  bowel 
obstruction,  it  is  .probably  either  intussusception  or  peritonitis. 

2.  When  an  elderly  person  is  the  patient,  the  diagnosis  will  generally 
rest  between  impaction  of  intestinal  contents  and  malignant  disease  (stric- 
ture or  tumor). 

3.  In  middle  age  the  causes  of  obstruction  may  be  various;  but  intus- 
susception and  malignant  disease,  both  of  them  common  at  the  extremes, 
are  now  very  unusual. 

4.  Intussusception  cases  may  be  known  by  the  frequent  straining,  the 
passage  of  blood  and  mucus,  the  incompleteness  of  the  constipation,  and 
the  discovery  of  a  sausage-like  tumor,  either  by  examination  per  anum 
or  through  the  abdominal  walls. 

5.  In  intussusception,  the  parietes  usually  remain  lax,  and,  there  being 
but  little  tympanites,  it  is  almost  always  possible,  without  much  diffi- 
culty, to  discover  the  lump  (or  sausage-like  tumor)  by  manipulation  under 
ether. 

6.  Malignant  stricture  may  be  suspected  when,  in  an  old  person,  con- 
tinued abdominal  uneasiness  and  repeated  attacks  of  temporary  constipa- 
tion have  preceded  the  illness.  It  is  to  be  noted  also  that  the  constipa- 
tion is  often  not  complete. 

7.  If  a  tumor  be  present  and  pressing  on  the  boAvel,  it  ought  to  be 
discoverable  by  palpation,  under  ether,  through  the  abdominal  walls,  or 
by  examination  by  the  anus  or  vagina,  great  care  being  taken  not  to  be 
misled  by  scybalous  masses. 

8.  If  repeated  attacks  of  dangerous  obstruction  have  occurred  with  long 
intervals  of  perfect  health,  it  may  be  suspected  that  the  patient  is  the  sub- 


DISEASES   OF   THE   DIOESTIVE   SYSTEM.  107 

ject  of  a  congenital  diverticulum,  or  has  bands  of  adhesion,  or  that  some 
part  of  the  intestine  is  pouched  and  liable  to  twist. 

9.  If,  in  the  early  part  of  a  case,  the  abdomen  become  distended  and 
hard,  it  is  almost  certain  that  there  is  peritonitis. 

10.  If  the  intestines  continue  to  roll  about  visibly,  it  is  almost  certain 
that  there  is  no  peritonitis.  This  symptom  occurs  chiefly  in  emaciated 
subjects,  with  obstruction  in  the  colon  of  long  duration. 

11.  The  tendency  to  vomit  will  usually  be  relative  with  three  condi- 
tions and  proportionate  to  them.  These  are  (1)  the  nearness  of  the  im- 
pediment to  the  stomach,  (2)  the  tightness  of  the  constriction,  and  (3)  the 
persistence  or  otherwise  with  which  food  and  medicine  have  been  given 
by  the  mouth. 

12.  In  cases  of  obstruction  in  the  colon  or  rectum,  sickness  is  often 
wholly  absent. 

13.  Violent  retching  and  bile  vomiting  are  often  more  troublesome  in 
cases  of  gall-stones  or  renal  calculus  simulating  obstruction  than  in  true 
conditions  of  the  latter. 

14.  Fecal  vomiting  can  occur  only  when  the  obstruction  is  moderately 
low  down.  If  it  happen  early  in  the  case,  it  is  a  most  serious  symptom, 
as  implying  tightness  of  constriction. 

15.  The  introduction  of  the  hand  into  the  rectum  as  recommended  by 
Prof.  Simon,  of  Kiel,  may  often  furnish  useful  information. 

INFLAMMATORY   DIARRHXEA    (ENTERITIS)    AND    DYS- 
ENTERY (COLITIS). 

These  diseases,  both  alike  in  being  inflammations  of  the  mucous  mem- 
brane of  the  intestinal  tract,  are  frequently  associated.  But  for  thera- 
peutic as  well  as  prognostic  purposes,  it  is  desirable  to  recognize  the 
distinctions  which  they  present  in  well  marked  types.     They  are — 

ENTERITIS.  DYSENTERY. 

Seat  of  inflammation  is  in    the        Seat  of  inflammation  is   in    the 

small  intestine.  large  intestine. 

Usually  begins  with  colic,  nausea        Usually  begins  with  painless,  slight 

and  vomiting,  constipation    (rarely  diarrhoea,  followed   by  chill,  slight 

diarrhoea),  chilliness  soon   followed  or  no  fever,  sense  of  weight  near  the 

by  high  fever,  thirst  and  hot  skin.  anus.     No  colic. 


L98 


lUFFEKENTlAI.    [»1A«:.N«>SIS. 


ENTERITIS. 

Pulse  at  first  tense  and  full  j  soou 
becomes  small,  wiry,  quick. 

Pain  paroxysmal, local  tenderness 
marked,  greatly  increased  by  pres- 
sure. 

Stools  mucous,  rarely  blood,  very 
rarely  pus.  Noscybala.  No  tenes- 
mus. 

Aortic  pulsation  felt  by  the  pa- 
tient on  the  right  of  the  umbilicus. 


DVSKXTHUY. 

Pulse  often  little  excited  ;  or  if 
fever  is  high,  full  and  rapid. 

Pain  more  moderate,  usually  dis- 
tinctly over  the  colon,  moderate  ten- 
derness. 

Stools  scanty,  bloody,  contain  pus, 
scybala,  little  faeces.  Marked  tenes- 
mus. 

Aortic  pulsation  not  noticed  by 
the  patient. 


DISEASES  OF  THE  LIVER. 

Previous  to  an  examination  of  the  liver,  the  patient  should  have  a  free 
action  of  the  bowels,  as  fecal  accumulations  are  a  constant  cause  of  diag- 
nostic  errors.  Pie  should  lie  on  his  back  on  a  firm  bed,  with  his  knees 
drawn  up  and  the  abdominal  muscles  relaxed.  Palpation  should  be  upon 
the  skin  directly,  uot  on  the  clothing.  The  physician,  seating  himself  on 
the  patient's  right  side,  should  apply  the  tips  of  the  fingers  of  the  right 
hand  just  below  the  free  border  of  the  ribs,  and  request  the  patient  to 
make  full  inspiration  and  expiration.  He  will  thus  be  able  to  feel  the 
upper  edge  and  surface  of  the  liver  and  ascertain  the  condition  of  its  sur- 
face, whether  smooth  or  nodular.  By  percussion,  which  should  be  made 
while  the  patient  is  in  the  same  position,  the  size  of  the  liver  cau  be  quite 
accurately  mapped  out.  These  two  facts  are  the  first  steps  to  a  diagnosis; 
as  most  hepatic  diseases  can  be  assigned  to  one  of  these  classes — 

1.  Liver  enlarged,  with  smooth  surface. 

2.  Liver  enlarged,  with  nodular  surface. 

3.  Liver  atrophied. 

Pain  iu  the  hepatic  region  should  be  examined  ;  whether  dull  or  acute, 
persistent  or  intermittent,  etc.  The  condition  of  jawndine  is  ascertained, 
iu  light  cases,  by  examining  the  under  surface  of  the  tongue  and  the  con- 
junctiva of  the  eye,  which  will  display  the  icteric  discoloration  when  the 
general  surface  does  not.  A  still  more  delicate  test  of  the  presence  of 
jaundice  is  derivable  from  examination  of  the  urine.  The  following  three 
teste  are  employed  by  Pro!'.  Hardy,  of  Paris: — 


DISEASES   OF  THE   DIGESTIVE   SYSTEM.  199 

1.  Chloroform.  When  this  is  poured  upon  normal  urine  it  sink-,  by 
reason  of  its  great  density,  to  the  bottom  of  the  test-glass,  exhibiting  there 
a  crystalline  transparency.  If  we  pour  it  on  the  icteric  urine,  and  having 
shaken  the  test-tube  plugged  by  the  thumb,  leave  it  quiet  for  a  moment, 
the  chloroform  deposit  contrasts  strongly  by  its  dull  color  with  the  yellow 
of  the  superficial  layers — the  yellow  color  being  deeper  in  proportion  to 
the  quantity  of  bile  in  the  urine.     It  is  an  excellent  test  of  icteric  urine. 

2.  Iodine.  When  the  iodine  is  poured  upon  the  icteric  urine  the  mix- 
ture must  not  be  shaken.  At  the  upper  part  of  the  tube  three  very  dis- 
tinct colors  are  observable — the  first  layer  formed  by  the  tincture  is 
violet;  below  this  is  a  kind  of  diaphragm  of  sea-green  color;  and  the 
third  layer,  consisting  of  the  urine,  and  occupying  the  lowest  part,  is 
yellow. 

3.  Nitric  Acid.  When  this  agent  has  been  poured  in,  the  mixture  after 
shaking  assumes  a  bottle-green  color,  passing  into  an  olive.  This  is  an 
entirely  special  aud  very  characteristic  appearance.* 

With  these  hepatic  symptoms  determined,  a  study  of  the  following 
tables  will  in  most  instances  readily  supply  a  correct  diagnosis. 

THE  SIGNIFICANCE  OF  PAIN  IN  THE  LIVER. 

Pain  having  its  source  in  the  liver  is  divided  by  Dr.  Charles  Mur- 
CHisoNf  into  three  varieties,  each  of  diagnostic  significance : — 

CHARACTER  OF  PAIN.  DISEASES  FOUND  IN. 

Obstruction  of  the  bile  duct  by 
gall-stones,  etc.  (hepatic  colic);  hep- 
atic neuralgia  (when  jaundice  is  ab- 


I.  Pain  severe,  paroxysmal,  with 
distinct  intermissions;  little  or  no 
local  tenderness;  no  fever;  often 
associated  with  jaundice. 

II.  Pain  moderate,  continuous, 
slightly  increased  by  pressure,  often 
associated  with  pain  in  the  right 
shoulder,  slight  febrile  symptoms 
and  jaundice. 

III.  Pain  severe,  constant,  greatly 
increased  by  pressure,  motion,  cough- 
ing, etc.  More  or  less  fever;  per- 
haps jaundice. 


sent,  probably  the  latter). 

Congestion  and  commencing  in- 
flammation of  the  organ;  catarrh 
and  partial  obstruction  of  the  bile 
ducts;  acute  atrophy. 

Always  indicates  inflammation  of 
the  capsule  (peri-hepatitis),  which 
may  supervene  in  various  diseases 
(cirrhosis,  hydatids,  etc.). 


*  Revue  cle  Tlierapeutique,  August,  1878. 
f  "Lectures  on  Diseases  of  the  Liver." 


200  DIFFERENTIAL   DIAGNOSIS. 

Hepatic  pain  may  be  simulated  by  various  other  conditions.  The 
principal  ones,  with  their  characteristic  differences, are  as  follows: — 

1.  Pleurodynia.  The  pain  is  strictly  localized  to  a  small  spot.  Ab- 
sence  of  hepatic  disturbance. 

•_'.  Intercostal  Neuralgia.  Tender  points  along  the  course  of  the  inter- 
costal nerve.  Chiefly  referred  to  three  points  in  the  course  of  the  nerve: 
(1)  The  vertebral  groove;  (2)  The  axillary  region;  (3)  The  termination 
of  the  nerve  in  front.  Co-existence  of  neuralgia  elsewhere.  Absence  of 
hepatic  symptoms. 

3.  Pleurisy.     Presence  of  pyrexia  and  physical  signs  of  the  disease. 

4.  Gastrodynia.  Comes  on  with  relation  to  food  (stomach  always 
either  full  or  empty).     Pyrosis. 

5.  Intestinal  Colic.  Pain  referred  to  the  umbilical  region.  No  jaun- 
dice.    Blue  line  of  lead  poisoning.     Errors  of  diet. 

6.  Penal  Colic.  Pain  chiefly  referred  to  one  kidney,  when  it  shoots 
to  the  testiele  and  down  the  thigh.  No  jaundice.  Hematuria  and  renal 
calculus. 

Little  or  no  hepatic  pain  is  felt  in — 

1.  The  waxy,  lardaceous,  or  amyloid  liver. 

2.  The  fatty  liver. 

3.  Simple  hepatic  hypertrophy. 

4.  Hydatid  tumor. 

THE  SIGNIFICANCE  OF  JAUNDICE. 

The  common  and  obvious  symptom  of  jaundice  results  either  (1)  from 
obstructions  of  the  common  bile  duct ;  or  (2)  independent  of  any  obstruc- 
tion of  the  duct.  The  diagnosis  of  these  two  conditions  may  be  presented 
as  follows : — 

JAUNDICE  FROM  OBSTRUC-  JAUNDICE  WITHOUT  OBSTRUC- 

TION. TION. 


When  persistent,  speedily  be- 
comes int( 

The  stools  are  elay-eolorcd. 

Tumor  in  the  region  of  the  gall- 
bladder often  present. 

May  appear  suddenly  in  a  person 
in  good  health. 


Persists  and  continues  slight. 

The  stools  are  natural. 
No  tumor  there. 

Appears  gradually,  unless  there  is 
a  history  of  shock. 


DISKAKKH    OF    TIIIO    Did  KSTI VK    SVS'I'KM. 


201 


JAUNDICE  FROM  OBSTRUC- 
TION. 

Intermittent  jaundice  in  advanced 
life  signifies  gall-stones. 

Pain,  usually,  in  severe  parox- 
ysms. 

Co-existence  of  ascites,  pregnancy, 
pyloric  cancer  (obstruction  from 
without). 


JAUNDICE  WITHOUT  OBSTRUC- 
TION. 

Intermittent  jaundice  in  youth 
signifies  catarrh  of  the  duodenum. 

Pain  usually  more  or  less  con- 
stant. 

Preceding  severe  mental  emotion, 
pyaemia,  malarial  fevers,  phospho- 
rus poisoning,  epidemic  prevalence. 


The  principal  diseases  which  are  associated  with  these  varieties  of 
jaundice  are  the  following : — 

JAUNDICE  FROM  OBSTRUCTION  MAY  BE  DUE  TO 


1.  Gall  Stones. 


2.  Hydatids. 


3.  Cancer  and  Tumors. 


DIAGNOSIS. 


Biliary  colic  present.  Pain  acute,  paroxys- 
mal, referred  to  the  gall  bladder,  and  from 
this  round  to  the  right  scapula.  Tenderness 
absent  or  slight.  Irregular  rigors.  No  fever. 
Severe  vomiting.  Jaundice  appears  after  a 
day  or  two.  Pathognomonic;  the  presence 
of  gall  stones  in  faeces. 

Liver  enlarged  and  altered  in  form  but 
painless.  Biliary  colic  with  fever,  quick  pulse 
and  high  temperature.  Pathognomonic;  hy- 
datid vesicles  in  the  faeces. 

Antecedent  history  of  visceral  cancerous 
disease.  Pain  and  nausea  after  taking  food. 
A  hard  and  sensitive  tumor  in  the  epigastric 
or  right  hypochondriac  region.  Hemorrhage 
from  the  stomach  or  bowels. 


JAUNDICE  WITHOUT  OBSTRUCTION  MAY  BE  DUE  TO 


1.  Malarial  Fevers. 
Yellow  Fever,  Pyaemia. 

2.  Epidemic  Jaundice. 


DIAGNOSIS. 


History  of  malarial  or  specific  poisoning,  or 
actual  presence  of  one  of  the  diseases  named. 

Gastric  catarrh;  stools  pale;  epigastric  sore- 
ness; nausea  or  vomiting;  loss  of  appetite; 
often  commences  with  a  chill  after  exposure. 
Most  epidemics  of  jaundice  seem  to  have  been 
due  to  malarious  poison  or  vitiated  atmosphere. 
Infantile  jaundice  is  of  the  latter  character. 


21 >2 


DIFF E  RENT1AL    DIAG  XOSIS. 


JAUNDICE  WITHOUT  OBSTRUCTION  MAY   HE   DEE  TO— (fW/«M<-,/) 


3.  Nervous  -Jaundice. 


Jaundice  from  Con- 
gestion'. 


DIAGNOSIS. 


History  of  severe  menial  emotion,  great 
suffering  or  sudden  shock.  Onset  rapid;  often 
cerebral  symptoms. 

Feeling  of  weight  and  soreness  over  liver. 
Bad  breath;  poor  appetite;  furred  tongue; 
vertigo.  Right  decubitus.  Urine  scanty  and 
high  colored.  Slight  dyspnoea.  Bowels  slug- 
gish. 


Acute  atrophy,  mineral  poisons  (especially  by  phosphorus),  and   very 
obstinate  constipation,  are  other  occasional  causes  of  this  form  of  jaundice. 


CLASSIFICATION  OF  HEPATIC  DISEASES  WITH  REGARD  TO  THE 
SIZE  OF  THE  LIVER.* 

1.  LIVER  ENLARGED,  SURFACE  SMOOTH. 


Simple  Hyperplasia. 
Hyper 


Liver  enlarged,  smooth,  painless;  absence 
of  other  symptoms. 

Liver  enlarged  and  smooth.  Spleen  en- 
larged. Pallor  of  the  skin.  Pathognomonic; 
presence  of  a  marked  increase  of  the  white 
blood  globules,  1:20  and  upward. 

Enlargement  moderate.  Tenderness;  con- 
junctiva jaundiced;  stools  pale;  bowels  irregu- 
lar; tongue  coated;  low  spirits;  headache; 
vertigo;  noises  in  the  ears.  No  jaundice  or 
dropsy. 

Liver  enlarged,  smooth.  Slight  jaundice. 
Some  dyspnoea.  Dropsical  effusions.  Mitral 
or  aortic  disease.  Emphysema  or  induration 
of  the  lungs. 

Enlargement  slight.  Enlarged  spleen. 
History  of  malarial  disease.  Pathognomonic: 
the  malarial  pigment  tn  the  blood. 

Enlargement  considerable,  uniform,  of  slow 
growth,  borders  sharply  defined,  feel  firm. 
Pain  slight.  Patient  emaciated  and  cachectic. 
Splenic  enlargement  common.  Diarrhoea  and 
dyspepsia.  History  of  phthisis,  syphilis  or 
protracted  suppuration. 

*  Partly  taken  from  E.  J.  Janeway.   "Diagnosis  of  Hepatic  Affections."   N.  Y.,  1877. 


Leukemic 

PLASIA. 

Congestion. 
(a)  Simple. 


(b)  From    cardiac    dis- 
ease. 


(c)  From  malaria. 


Waxy  Deg  ester ation. 


DISEASES    OF   THE    DIGESTIVE   SYSTEM. 


203 


CLASSIFICATION  OF  HEPATIC  DISEASES  WITH   IiEOAI.'O  TO  THE 
SIZE  OF  THE  LIVER. 

1.  LIVER  ENLARGED,  SURFACE  SMOOTH-( Continued). 


Enlargement  considerable,  borders  rounded, 
feel  doughy.  No  tenderness  nor  pain.  Spleen 
small;  jaundice  slight  or  absent.  Diarrhcea. 
A  pale,  smooth,  greasy  skin.  History  of  in- 
temperance, phthisis  or  indolent  life. 

Enlargement  considerable,  irregular,  pain- 
less; usually  of  the  left  lobe  of  the  organ. 
Feel  elastic  or  fluctuating.  Jaundice  rare. 
Increase  of  size  slow.  No  constitutional 
symptoms. 

Liver  small,  surface  even.  Preceded  by 
ascites,  dyspnoea,  serious  disease  of  heart  or 
lungs,  or  signs  of  congestion. 

Rare.  Jaundice  always  present,  though 
rarely  intense.  Pain  considerable.  Tender- 
ness. Generally  vomiting ;  splenic  dullness. 
Pulse  irregular.  The  typhoid  state  common. 
Urine  dark,  acid,  sp.  grav.  1.012-1.024;  ab- 
sence of  urea,  uric  acid  and  the  chlorides ; 
presence  of  leucine  and  tyrosine  (pathogno- 
monic). Intestinal  ^hemorrhage  and  hseina- 
temesis  common. 


II.  LIVER  ENLARGED,  SURFACE  NODULAR  OR  IRREGULAR. 


Fatty  Degeneration. 


Hydatid  Tumors. 


Simple  Atrophy. 


Acute  Yellow  Atro- 
phy. 


Abscess    or    Tropical 
Hepatitis. 


Cancer. 


Liver  enlarged,  irregular  surface  bulging. 
Dull,  heavy  pain.  Jaundice  rare.  Pyrexia 
and  chills.  History  of  residence  in  a  warm 
climate. 

Enlargement  often  very  great,  progressive, 
irregular;  nodular  excrescences  often  to  be 
felt.  Feel  hard  and  resistant.  Pain  lancin- 
ating and  tenderness  acute.  No  febrile  symp- 
toms. Jaundice.  "  The  co-existence  of  en- 
larged liver  with  persistent  jaundice  ought 
always  to  raise  the  suspicion  of  cancer" 
(Murchison).  Dyspepsia,  nausea,  vomiting, 
constipation,  or  diarrhoea,  short,  dry  cough, 
ascites.     Patients  over  40.     In  suspected  can- 


-  I 


DIFFERENTIAL    DIAGNOSIS. 


CLASSIFICATION  OF  HEPATIC  PISFASFS  WITH  REGARD  TO  THE 
SIZE  OF  THE  LIVER. 

II.  LIVER  ENLARGED,  SURFACE  NODULAR  OR  IRREGULAR-( Continued). 


(  Ianceb  (Continued). 


Syphilitic  Liver. 


cer  of  the  liver  the  urine  should  always  be 
examined;  half  a  drachm  of  strong  nitric 
acid  should  be  added  to  half  an  ounce  of  the 
urine.  If  the  fluid  changes  to  a  dark  or  black 
hue,  and  especially  if  no  albumen  is  present, 
and  the  liver  is  either  increased  or  diminished 
in  size,  the  diagnosis  of  melanotic  cancer  is 
rendered  very  probable.  (Dr.  ElSELT,  of 
Prague.) 

Liver   enlarged,  surface   nodulated,   lobes 
irregular,  separated  by  deep  fissures. 

III.  LIVER  DIMINISHED  IN  SIZE. 


Cirrhosis,  or  Chronic 
Atrophy. 


Liver  small,  sometimes  only  half  size,  sur- 
face granular  or  nodulated  ;  "  hob-nail  liver." 
Outset  insidious,  with  signs  of  disordered  di- 
gestion. Dull  pain  and  slight  tenderness  in 
hepatic  region.  Ascites  common.  Spleen 
often  enlarged.  Superficial  veins  of  the  ab- 
domen enlarged.  Hemorrhoids  frequent. 
Jaundice  rare  or  slight.  Progressive  emacia- 
tion and  debility.  History  of  spirit  drinking 
almost  invariably. 

HEPATIC  ABSCESS. 

It  has  lately  been  shown  *  that  an  obscure  and  chronic  form  of  hepatic 
abscess  is  a  far  more  common  disease  in  the  United  States  than  is  generally 
supposed,  and  that  it  is  often  exceedingly  difficult  of  diagnosis. 

These  abscesses  may  exist  without  any  local  symptoms  or  such  general 
disturbance  of  the  system  as  is  commonly  regarded  as  indicating  their 
presence,  and  are  a  very  common  concomitant  of  prolonged  malarial 
poisoning.  The  pathognomonic  sign  of  their  presence  is  the  discovery 
of  pus  on  aspiration  of  the  parenchyma  of  the  liver.  This  operation  is 
not  dangerous,  and  there  need  be  no  hesitation  in  its  performance.  The 
place  of  election  is  one  of  the  intercostal  spaces.  The  rational  symp- 
toms may  be  collated  as  follows: — 

J  .,   SCKT,  Med.  Record,  April  20th,  1878;  Hammond,  St.  Louis  Clin.  Record,  Juno 
1878 ;  Bykd,  N.  Y.  Med.  Journal,  July,  1878,  etc. 


DISEASES   OF   THE   DIGESTIVE  SYSTEM.  205 

1.  Gastric  and  intestinal  derangements ;  dyspeptic  symptoms  of  various 
kinds. 

2.  Slight  jaundice,  conjunctivae  yellow;  complexion  sallow. 

3.  Depression  of  spirits,  hypochondria  or  melancholy.  This  is  a  very 
usual  symptom,  and  so  important  that  Dr.  Hammond  recommends  that 
in  all  cases  of  hypochondria  or  melancholia  the  region  of  the  liver  should 
be  carefully  explored,  and  even  if  no  fluctuation  be  detected,  or  any  other 
sign  of  abscess  be  discovered,  aspiration,  with  proper  precautions,  should 
be  performed.  If  pus  be  evacuated,  the  operation  may  be  expected  to  be 
followed  by  a  cure  of  the  mental  disorder,  as  well  as  by  the  preservation 
of  the  life  of  the  patient  from  the  probably  fatal  consequences  of  hepatic 
abscess. 

4.  Sense  of  weight  or  pain  in  the  right  side ;  more  or  less  tenderness 
on  pressure  (all  local  symptoms  often  absent). 

5.  Circumscribed  fluctuation  over  the  hepatic  region.  This  is  a  posi- 
tive sign,  but  is  by  no  means  always  to  be  discovered. 

6.  Cerebral  symptoms,  as  vertigo,  cephalalgia,  insomnia  hysteria  and 
hyperaemia. 

7.  Slight  rigors,  and  feverishness,  simulating  some  of  the  more  chronie 
forms  of  intermittent  fever. 

INTERNAL  PARASITES. 

The  symptoms  to  which  parasites  in  the  intestinal  canal  and  other 
organs  give  rise  are  numerous,  but  by  no  means  specific  or  definite. 
The  following  tabular  arrangement  sets  forth  the  more  prominent : — 


Tape  Woem. 
Taenia  Solium. 
Taenia  Saadnata. 


Pain  and  discomfort  in  the  belly ;  variable 
appetite;  constipation  and  diarrhoea  alternat- 
ing; itching  at  the  nose  or  anus  without  local 
cause,  low  spirits,  loss  of  flesh,  nervous  seiz- 
ures.    Stools  unusually  dark  or  light. 

Pathognomonic:  The  discovery  of  joints  in 
the  stools,  or  about  the  anus,  or  of  eggs  in  the 
faeces  (microscopic). 


206 


DIFFERENTIAL    MACNOSIS. 


Hydatid  (  Iysts. 
Taenia  Echinococci. 


Round     Worms,    Lum- 
brici. 
Ascaris  Lumbricoides. 


Thrf.ad  Worms. 

Ascaris  Vermicularis  or 
Oxyuris  Vermicularis. 


Trichinosis. 

(Trichinae  in  the  blood 
and  muscular  system). 

Trichina  Spiralis. 


These  occur  chiefly  in  the  lungs  and  liver. 

(Sir  Diseases  of  the  Liver.)  They  begin  with 
a  rounded,  tense,  smooth,  clastic  swelling, 
painless  until  inflammation  begins,  and  with- 
out other  symptoms  than  those  caused  bytheir 
size.  They  are  often  attended  with  the 
"  hydatid  thrill."  This  may  be  felt  by  plac- 
ing the  left  hand  flat  and  closely  upon  the 
tumor,  then  percussing  sharply  with  the  fingers 
of  the  right  hand.  A  long  sustained  tremor 
is  observed,  "like  that  experienced  on  an  iron 
railway  bridge  during  the  passage  of  a  train." 
Pathognomonic:  Echinococci  or  microscopic 
hydatids  in  the  contained  fluid,  which  may 
safely  be  drawn  by  aspiration. 

Symptoms  of  intestinal  irritation.  Capri- 
cious appetite.  Pain  of  a  gnawing  or  griping 
character.  Tenderness  on  deep  pressure  over 
the  abdomen.  Tumid  condition  of  the  belly. 
Alternate  constipation  and  diarrhoea.  The 
tongue  pale,  flabby,  indented  by  the  teeth,  and 
often  has  a  peculiar  shiny  appearance.  Pupils 
generally  dilated.  Squinting,  nervous  twitch- 
ings,  or  even  convulsions.  Sleep  is  restless, 
with  grating  of  the  teeth  and  waking  with 
sudden  starts.  Fever  may  appear,  often  of  a 
remittent  type  (worm  fever,  verminal  fever). 

Pathognomonic:  Worms  found  in  alvine 
evacuations. 

Violent  itching  and  irritation  at  the  anus 
and  vagina,  increased  at  night.  Tendency  to 
strain.     Itching  at  the  nose.     Leucorrhcea. 

Pathognomonic :  Worms  found  upon  ex- 
amining the  parts,  also  seen  in  patient's  bed 
and  his  under-clothing. 

First  Stage:  Gastro-intcstinal  disturbances; 
thirst;  loss  of  appetite;  nausea;  colicky  pain 
in  the  abdomen;  constipation  or  diarrhoea; 
coated  tongue;  feverishness.  Second  Stage: 
Swelling  and  stiffness  of  the  muscles;  muscu- 
lar soreness ;  oedema  of  the  subcutaneous 
tissue;  copious  sweating;  debility  and  increased 


DISEASES    OF   THE    DIGESTIVE   SYSTEM. 


207 


Trichinosis  (Continued),  fever;  dyspnoea;  hoarseness  and  loss  of  voice; 

dropsy  commencing  in  the  eyelids  and  face, 
and  proceeding  to  the  extremities;  difficulty 
of  motion  and  respiration. 

Pathognomonic:  Presence  of  trichinae  in 
the  fasces;  or  in  the  muscular  structure. 

The  differential  diagnosis  from  rheumatism 
is  in  the  soreness  being  in  the  muscles  and 
not  the  joints;  from  typhoid  fever'  in  the  un- 
usual pain  and  stiffness;  the  early  swelling, 
dropsy,  etc. 

Trichinae  do  not  colonize  equally  through- 
out a  muscle,  but  in  groups  here  and  there. 
It  is  best,  therefore,  to  dissect  out  a  muscle 
lengthwise  in  order  to  judge  of  their  number. 

The  very  large  number  of  symptoms  attributed  to  the  presence  of 
worms  in  the  intestinal  canal  is  the  irritation  they  cause,  implicating  the 
general  nervous  system.  This,  occasionally,  extends  so  far  as  to  produce 
a  "worm  fever,"  which  in  many  respects  resembles  a  mild  remittent  with 
unusually  pronounced  nervous  symptoms.  The  tongue  is  pale  and  flabby, 
and  often  has  a  peculiar  shiny  appearance  (Date).  The  pupils  are  gene- 
ally  dilated.  Squinting  sometimes  occurs,  and  nervous  twitchings  of  a 
choreic  character.  The  fever  is  often  high,  with  great  heat  of  skin,  and 
the  cerebral  manifestations  being  marked,  may  lead  to  the  suspicion  of 
hydrocephalus.  From  this  it  can  be  distinguished  by  the  mere  direct 
remissions;  by  the  previous  history,  showing  the  primary  symptoms  to  be 
referable  to  derangements  of  the  alimentary  canal ;  by  the  less  obstinate 
constipation;  and  by  the  expulsion  of  worms. 

It  has  also  been  confounded  with  tubercular  disease.  Here  the  most 
important  diagnostic  point  is  the  temperature.  This  in  tubercular  disease 
is  always  high;  but  when  the  irritation  is  from  worms  it  is  either  normal 
or  but  temporarily  elevated  above  the  normal  standard. 


208  DIFFERENTIAL   DIAGNOSIS. 

CHAPTER  V. 

DISEASES  OF  THE  URINARY  SYSTEM. 

The  Early  Signs  of  PrighCs  Disease — Comparative  Diagnosis  of  the 
Dijf'erent  Forms  of  Brighfs  Disease  (Acute  Parenchymatous  Nephritis, 
Chronic  Tubal  Nephritis,  Yellow  Fatty  Kidney,  Secondary  Contraction 
of  Kidney,  Interstitial  Nephritis  or  Renal  Cirrhosis,  Albuminoid  or 
Amyloid  Renal  Degeneration,  Parenchymatous  Renal  Degeneration) — 
Diabetes  Mellitus  and  Glycosuria — Diabetes  Insipidus  and  Hydruria — 
Pile  in  the  Urine — Urinary  Calculi. 

General  methods  for  the  examination  of  the  urine,  and  the  chemical 
reagents  and  manipulations  required  in  its  analysis,  are  to  be  found  in  so 
many  text-books  and  treatises  that  we  may  omit  them  here,  and  confine 
ourselves  to  the  differential  symptoms  of  some  of  the  most  prominent  and 
frequent  renal  diseases. 

THE  EARLY  SIGNS  OF  BRIGHT'S  DISEASE. 

The  early  progress  of  Bright's  disease  is  often  remarkably  insidious, 
and  readily  escapes  recognition.  Nor  is  it  to  be  detected  by  the  familiar 
and  easy  plan  of  testing  for  albumen ;  for  this  substance  is  by  no  means 
invariably  present  in  the  urine,  even  in  advanced  and  well  marked  cases. 
Fothergill  justly  observes  that  the  progress  of  interstitial  nephritis  is 
often  without  the  albuminous  secretion  for  long  periods. 

On  the  other  hand,  it  has  been  abundantly  shown  that  albumen  is 
occasionally  and  transiently  present  in  the  urine  of  persons  who  present 
no  traces  of  nephritis;  who,  in  fact,  may  be  in  excellent  health. 

Hence  the  value  of  other  means  of  determining  the  existence  of  these 
forms  of  renal  disease  becomes  manifest.  Of  these  the  presence  of  hyedine 
casts  has  recently  been  urged  as  pathognomonic  of  renal  hyperemia  and 
inflammation,  and  invariably  present.*  These  must  be  sought  for  with 
considerable  care,  as  from  their  transparent  character,  and  the  fact 
*Dr.  B.  A.  Segur,  Proceedings  of  the  Medical  Society  of  King's  Co.,  1878,  p.  241. 


DISEASES   OF   THE   URINARY  SYSTEM.  209 

that  they  do  not  form  a  sediment,  they  are  readily  overlooked.  The  di- 
rections given  for  their  search  are  that  the  urine  to  be  examined  is  placed 
in  a  tall,  conical  glass;  after  three  to  six  hours  it  is  inspected;  from  the 
visible  deposits,  whether  floating  or  sedimentary,  with  the  pipette  a 
quantity  is  taken  sufficient  to  fill  a  concave  slide  or  a  shallow  cell. 

This  little  pool  is  first  searched  with  a  four-tenths  objective,  and  in  a 
little  time  any  cast  or  other  microscopic  object  it  contains  is  found.  A 
more  careful  observation  is  made  of  the  object  thus  found  with  the  one- 
fifth.  When  the  examination  of  deposits  has  been  made  in  this  way,  the 
conical  glass  of  urine  should  be  set  aside  (a  little  chloral  may  be  added,  to 
prevent  decomposition),  and  after  twelve  hours  more  the  examination 
should  be  repeated.  Of  course,  it  will  be  remembered  that  the  hyaline 
cast  may  be  found  when  the  condition  of  the  kidney  is  only  one  of  tran- 
sient hyperemia. 

The  effort  has  also  been  made  to  call  in  the  aid  of  the  ophthalmoscope. 
The  presence  of  minute  white  exudations  in  the  retina,  principally  around 
the  macula?  luteee,  are  believed  to  point  to  the  presence  of  Bright's  dis- 
ease, and  to  be  found  in  its  early  stages  (retinitis  albumin urica).  The 
appearance  of  the  retina  in  these  cases  is  characteristic.  It  consists  in  the 
grouping  of  small  white  spots,  the  outline  of  each  being  clearly  defined ; 
they  are  invariably  circular,  of  extremely  small  dimensions,  and  present 
the  appearances  of  a  pearl  of  an  intensely  bright  color,  and  stand  out  from 
the  retina  in  a  marked  manner.  The  grouping  of  the  spots  is  symmetri- 
cal in  each  eye,  and  is  generally  in  the  form  of  a  crescent.  Often  the 
urine  will  only  yield  signs  of  the  minutest  quantities  of  albumen — some- 
times none  at  all ;  but  hyaline  casts  and  these  white  spots  may  be  detected 
by  the  processes  here  described. 

We  shall  now  proceed  to  classify  the  diagnostic  points  in  the  differen- 
tiation of  the  seven  forms  into  which  the  varieties  of  Bright's  disease  are 
now  divided,  premising  that  more  than  one  form  may  exist  in  the  same 
patient. 


210 


DIFFERENTIAL    DIAGNOSIS. 


COMPARISON  OF  THE  DIFFERENT 


History. 


Appearance. 


Urine. 


Prognosis. 


Pathology. 


ACUTE     DESQUAMATIVE 
NEPHRITIS. 


Sudden  onset  after 
Bcarlel  fever  or  ex- 
posure to  wet  and 
cold;  OSdema  of  the 
face  the  sign  first 
noticed;  headache, 
feverishness,  pain 
in  the  loins,  gastric 
disturbance. 


Dropsical. more  or  less 
swollen  about  the 
face ;  skin  generally 
dry. 


Scanty,  smoke  color- 
ed, dark  when  acid, 
red  if  alkalized. 
Highly  albuminous. 
Specific  gravity 
high,  1.025-1.030. 
Reddish  brown  sedi- 
ment of  epithelial, 
blood  and  hyaline 
casts. 

Recovery  frequent. 
May  lead  to  chronic 
tubal  nephritis. 


Kidneys  enlarged, 
congested,  vascular; 
cortical  substance 
increased.  Tubules 
dark  and  dense. 


CHRONIC   TUBAL 
NEPHRITIS. 


Symptoms  of  more 
than  six  weeks'  du- 
ration. Often  his- 
tory of  acute  ne  |  ih  li- 
tis. Uremic  symp- 
toms; abnormal  ly 
1  o  w  temperature. 
Serous  inflamma- 
tions. Cardiac  hy- 
pertrophy. 

More  or  less  oedema, 
and  general  anasar- 
ca. A  pale,  almost 
characteristic,  waxy 
look. 

Generally  scanty, 
though  variable. 
Pale, albumen  about 
one-fourth,  specific 
gravity  low,  1.005- 
1.015 ;  white  sedi- 
ment of  hyaline  and 
epithelial  casts.  No 
blood  casts. 


Recovery  not  likely. 


Kidney  enlarged,  cor- 
tical substance  in- 
creased, capsules 
easily  separated. 
"Large  white  kid- 
ney." 


YELLOW    FATTY 
KIDNEY. 


Often  follows  alcohol- 
ism. 


Dropsy  considerable 
and  persistent;  re- 
nal cachexia  often 
marked. 


Scanty,  pale,  low  spe- 
cific gravity,  with 
abundant  sediment 
of  oil  casts  and  cells 
filled  with  oil.  Al- 
bumen abundant. 


Almost   certainly    fa- 
tal. 


Kidneys  e  nl  arge  d, 
fatty,  mottled,  the 
tubes  full  of  fat  and 
oil  cells. 


DISEASES   OF  THE   URINARY   SYSTEM. 


211 


FORMS  OF  BRIGHT'S  DISEASE. 


SECONDARY  CONTRAC- 
TION OF  KIDNEY. 


Symptoms  of  more 
than  a  year's  dura- 
t  i  o  n  .  Headache. 
Coma  o  r  convul- 
sions. Cardiac  hy- 
pertrophy. E  p  i  s  - 
taxis. 


Generally  some 
dropsy,  but  not  very 
extensive.  Face 
sallow. 


Scanty,  pale,  specific 
gravity  about  1  015. 
Albumen  moderate. 
Sediment  of  pale 
casts,  dark  granules, 
fatty  cells  and  waxy 
products. 


Generally  fatal,  but  of 
slow  progress. 


Kidneys  contracted, 
dense,  capsule  ad- 
herent; atrophy  of 
the  tubules. 


INTERSTITIAL 

NEPHRITIS. 

RENAL  CIRRHOSIS. 


Symptoms  few  and 
faint.  Often  the 
arthritic  diathesis. 
Exposure  to  cold 
and  fatigue.  Sense 
of  weariness.  Fre- 
quent headaches. 
Amaurosis.  Car- 
diac hypertrophy. 


Little  or  no  dropsy. 
Nerve  implications, 
as  paralysis,  loss  of 
sight  or  hearing, 
etc. 

Largely  increased, 
pale  ;  albumen  trifl- 
ing; sediment  little, 
of  finely  granular 
casts,  or  minute  oil 
drops.  Specific 
gravity  low. 


With  care,  not  imme- 
diately dangerous, 
but  predisposes  to 
uraemic  attacksfrom 
exposure. 

Kidneys   at   first    en- 
larged,   later    con- 
tracted ;  connective 
tissue      increased 
capsule     adherent 
diminished  and  cor 
rugated.      "Chron 
ically   contracted  ' 
kidney. 


ALBUMINOID  OR 
AMYLOID  RENAL 
DEGENERATION. 


Antecedent  syphilis, 
phthisis  or  osseous 
disease  of  chronic 
suppuration.  En- 
larged liver  or 
spleen.  Chronic 
diarrhoea. 


Dropsy  generally 
amenable  to  treat- 
ment. Emaciation. 
Face  sallow  or  pal- 
lid.    Dyspnoea. 

Largely  increased. 
(50-60  oz.)  pale  or 
golden ;  albumen 
considerable,  per- 
haps one-half.  Spe- 
cific  gravity  1.007- 
1.015 ;  little  or  no 
sediment ;  casts  hy- 
aline and  waxy. 


Incurable,  though  the 
patient  may  live  for 
years. 


Kidney  enlarged, 
smooth,  waxy  look- 
ing. 


PARENCHYMA- 
TOUS RENAL 
DEGENERATION. 

Pregnancy, 
diphtheria,  or 
acute  fever. 


Generally 
dropsy. 


Normal  in 
amount.  Al- 
bumen t1^  to  \ 
bulk. 


Recovery     fre- 
quent. 


Kidney  en- 
larged, the 
parenchyma 
more  or  less 
hypertro- 
phied. 


212  DIFFERENTIAL   DIAGNOSIS. 

In  the  form  of  amyloid  degeneration  the  difficulties  of  diagnosis  are 
considerable,  as  not  only  has  it  been  generally  recognized  that  albumen 
may  be  absent  for  considerable  periods  while  the  disease  is  steadily  ad- 
vancing, but  it  has  been  abundantly  shown  that  it  may  never  appear  at 
all  in  fatal  cases.* 

It  seems,  therefore,  certain  that  we  possess  at  present  no  sure  diagnostic 
sign  of  amyloid  degeneration  of  the  renal  vessels;  that  on  the  one  hand,  it 
is  likely  to  be  confounded  with,  or  mistaken  for,  chronic  parenchymatous 
nephritis  arising  under  identical  etiological  conditions;  on  the  other,  it 
runs  a  great  risk  of  being  altogether  overlooked.  But  both  of  these  evils 
may  be  avoided  with  a  little  care.  Bartels  points  out  that  the  differ- 
ential diagnosis  between  amyloid  disease  and  chronic  parenchymatous 
nephritis  depends  upon  the  distinguishing  characters  of  the  urine,  which, 
in  the  former,  is  clear,  with  little  sediment  and  few  casts,  mostly  hyaline, 
and  scarcely  ever  blood-corpuscles ;  in  the  latter  it  is  always  more  or  less 
turbid,  with  considerable  sediment,  is  dirty  colored,  contains  many  casts 
of  every  variety,  and  not  uncommonly  blood-corpuscles.  In  those  cases 
in  which  no  albumen  was  present,  there  have  been  signs  of  amyloid  dis- 
ease in  other  organs;  and,  in  order  to  escape  error,  it  will  be  enough  to 
know  that  the  absence  of  albumen  from  the  urine  does  not  exclude  a 
slight  degree  of  amyloid  disease  of  the  kidneys. 

Cystic  kidney  is  not  considered  worthy  of  special  remark,  since  ordi- 
nary cysts  are  not  to  be  recognized  with  any  certainty  during  life,  nor 
can  they  always  be  distinguished  from  the  chronic  varieties  of  Bright's 
Disease,  in  which  they  frequently  are  developed  (Da  Costa). 

DIABETES  MELLITUS  AND  GLYCOSURIA. 

The  presence  of  sugar  in  the  urine  is  characteristic  of  both  these  condi- 
tions. The  most  convenient  simple  test  is  caustic  potash  (Moore's 
test),  either  in  solution  or  small  fragments.  Heated  with  urine  containing 
sugar,  this  substance  immediately  produces  a  more  or  less  yellow  or  brown 
color,  the  intensity  of  which  is  in  proportion  to  the  quantity  of  sugar 
present,  and  a  peculiar  sweet  smell  (melassic  acid). 

The  test  usually  preferred  is  Trommer's  or  Fehling's,  which  depends 
upon  the  reduction  of  a  salt  of  copper  by  the  sugar.  The  Fehling's 
*Lecorch£,  "  Maladies  des  Reins,  Paris,  1875 ;  Littex,  Berliner  K  tin.  Wochenschrift. 


DISEASES   OF   THE   URINARY   SYSTEM. 


2i:s 


test  may  be  obtained  in  a  solid  form  as  "cupric  test  pellets,"  as  suggested 
by  Pavy.* 

Apart  from  this  test,  the  presence  of  sugar  in  the  urine  is  revealed  by 
many  indications.  We  may  often  recognize  it  by  grayish  patches  on  the 
clothing  or  linen,  which  are  reduced  to  powder  when  scratched  with  the 
nail.  In  women  the  chemise,  from  prolonged  contact  with  the  urine, 
may  become  spotted  and  stiffened,  as  if  by  drops  of  syrup.  Another 
circumstance  indicating  the  sugary  savor  of  the  urine,  especially  in  the 
country,  is  the  great  number  of  flies  or  ants  that  will  be  attracted  around 
the  vessel  containing  it. 

The  presence  of  sugar  once  determined,  it  remains  to  decide  whether  it 
arises  from  simple  glycosuria,  which  is  a  comparatively  common  and  not 
dangerous  condition,  or  from  saccharine  diabetes,  which  is  more  rare  and 
a  very  perilous  affection.  This  distinction  has  lately  been  insisted  upon 
by  M.  Gerin  Rozes.  The  contrasting  features  of  the  two  disorders 
may  be  presented  as  follows  : — 


DIABETES  MELLITUS. 

Onset  gradual ;  occurs  at  all  ages, 
and  without  reference  to  known  pre- 
disposing causes. 


The  amount  of  sugar  varies  very 
little. 

The  absence  of  saccharine  food 
makes  little  or  no  change  in  the 
urine. 

Volumetric  analysis  by  Fehling's 
method  is  easy. 

Polyuria,  polyphagia,  polydipsia, 
and  impotence  common  and  well 
marked. 

Nervous  complications  frequent. 

Treatment  of  little  avail ;  result 
usually  fatal. 


SIMPLE  GLYCOSURIA. 

Onset  sudden;  more  common  in 
the  aged ;  in  persons  consuming 
saccharine  food  ;  in  the  insane  ;  in 
those  taking  chloral ;  in  the  parox- 
ysms of  ague ;  after  sudden  excite- 
ment ;  blows  on  the  head ;  cerebral 
affections. 

The  amount  of  sugar  varies 
greatly  from  day  to  day  (pathogno- 
monic, Rozes). 

The  withdrawal  of  saccharine 
food  diminishes  the  sugar. 

Such  analysis  is  obscure,  owing 
to  the  quantity  of  creatinine  and 
similar  substances  present. 

All  these  may  be,  and  generally 
are,  absent,  or  slightly  marked. 

Rare. 

Treatment  eflicient ;  result  usually 
favorable. 


*  See  Article  by  Dr.  Neff,  in  Medical  and  Surgical  Reporter,  for  May  10th,  18S0. 


21-1  DIFFERENTIAL   DIAGNOSIS. 

"With  the  knowledge  of  the  very  fatal  character  of  diabetes  mellitus,  a 
recognition  of  its  earliest  symptoms  becomes  of  immense  importance  for 
treatment.  Its  invasion  is  seldom  sudden,  and  at  the  very  outset  may 
be  curable,  which  it  rarely  or  ever  is  when  once  developed. 

Various  nervous  symptoms  are  among-  the  earliest  noted,  and  it  is  a 
wise  rule  in  all  nervous  disorders  of  a  doubtful  character  to  examine  the 
urine  for  sugar.  Changes  in  the  character  of  an  individual,  an  abnormal 
irritability  of  temper,  insomnia,  and  extreme  feeling  of  fatigue,  disorders 
<>j  vision,  itching  of  the  skin,  pruritus  of  the  genital  organs,  especially  the 
vulva,  and  more  or  less  protracted  headache,  are  often  premonitory  symp- 
toms. Intense  and  obstinate  neuralgic  pains,  without  obvious  cause, 
especially  in  the  foot  and  leg,  should  lead  to  the  suspicion  of  diabetes. 
Recurrent  boils  and  carbuncles  arc  well  known  to  accompany  the  diabetic 
condition. 

Genital  impotence  is  one  of  the  first  signs  of  approaching  diabetes; 
and  whenever  individuals  are  met  with  who,  previously  virile,  become 
weak  and  impotent  without  coinciding  disease,  especially  of  the  spinal 
marrow,  diabetes  wrill  usually  be  found  to  be  the  cause.  Valuable  infor- 
mation is  derivable  from  the  mouth  ;  for  besides  the  insatiable  thirst  and 
dry  mouth,  some  patients  complain  of  a  disagreeable  taste,  which  is 
sometimes  acrid,  and  at  others  faint,  or  bitter,  or  sugary  ;  and  it  is  this 
perverted  taste  which  contributes  to  maintain  the  thirst. 

The  mouth  frequently  exhibits  an  aphthous  condition,  while  the  edges 
and  tip,  and  even  the  whole  surface  of  the  tongue,  may  present  a  red 
aspect,  as  if  the  aphtha?  had  been  removed.  The  gums,  also^  are  often 
softened,  fungous  or  bleeding;  while  in  some  the  teeth  become  loose,  or 
fall  out  without  being  decayed,  and  in  others  become  carious.  The 
breath  is  frequently  of  a  bad,  acid  smell,  and  the  saliva,  on  examination, 
is  acid  instead  of  neutral.  Another  fact  which  has  sometimes  led  to  the 
diagnosis  is  the  existence  of  intertrigo  at  the  commissure  of  the  lips. 
This  intertrigo  labialis  is  not  exclusively  connected  with  diabetes,  but 
when  met  with  should  always  lead  to  an  examination  of  the  urine. 

With  regard  to  the  digestive  organs,  boulimia  on  the  one  hand,  and  a 
complete  repugnance  for  food  on  the  other,  with  dyspepsia,  should  lead 
us  to  suspect  diabetes.  The  unusual  thirst  of  diabetics  prompts  them  to 
drink  large;  quantities  of  water  at  night,  and  such  a  habit  should  suggest 


DISEASES   OP  THE   URINARY  SYSTEM.  215 

strict  inquiry  for  other  symptoms.  As  a  general  rule  it  may  be  said  that 
whenever  there  is  muscular  debility,  emaciation  and  anaemia,  without 
discoverable  local  cause,  the  urine  should  be  examined,  and  will  almost 
always  be  found  to  contain  either  sugar  or  albumen. 

The  prognosis  in  a  case  of  Diabetes  Mcllitus  improves  with  the  age 
of  the  patient ;  occurring  in  elderly  persons,  with  ordinary  care,  it  does 
not  appear  to  shorten  life  (Da  Costa). 

DIABETES  INSIPIDUS  AND  HYDRUBIA. 

The  habitual  discharge  of  an  excessive  amount  of  urine  of  low  specific 
gravity,  and  containing  neither  albumen  nor  sugar,  if  accompanied  with 
progressive  emaciation,  excessive  thirst,  and  loss  of  vital  power,  constitutes 
diabetes  insipidus ;  but  under  various  conditions  excessive  diuresis  may 
be  temporarily  present,  as  in  hysteria  and  other  cerebro-spinal  and 
nervous  affections,  without  serious  general  symptoms,  and  constitute  the 
condition  of  hydruria.  The  distinction  between  the  two  can  be  made  by 
noting  the  coincident  disease  in  the  latter  form,  the  slight  direct  impairment 
of  the  general  health,  the  varying  amount  of  urine  voided,  and  by  the  fact 
that  the  quantity,  although  large,  never  attains  those  extraordinary  mea- 
sures— thirty  to  fifty  pints  daily — which  marked  cases  of  diabetes  insipidus 
present.  A  large  amount  of  urine  is  discharged  by  patients  with  amyloid 
degeneration  of  the  kidney. 

BILE  IN  URINE. 

The  significance  of  bile  in  urine  is  the  same  as  that  of  jaundice  (see 
page  200),  as  it  indicates  the  presence  of  bile  in  the  blood.  The  tests  are 
those  for  the  bile  pigment  and  those  for  the  biliary  salts.  The  color  test 
usually  employed  is  that  of  Gmelin ;  a  few  drops  of  urine  are  placed 
upon  a  white  plate  and  nitric  acid  dropped  at  its  side;  if  bile  pig- 
ment be  present  a  play  of  colors,  from  grass-green  to  red,  is  produced. 
The  same  may  be  obtained  by  adding  sulphuric  acid  to  urine  in  a  test 
tube,  and  dropping  in  a  crystal  of  potassium  nitrate.  The  tests  for  the 
biliary  salts  are  so  complicated  that  they  are  entirely  unreliable,  as  gener- 
ally applied.  For  cautions  and  directions  for  their  use  the  reader  is 
referred  to  Neubauer  and  Vogel's  "  Chemistry  of  the  Urine." 


21 G  DIFFERENTIAL   DIAGNOSIS. 

URINARY  CALCULI. 

There  are  but  three  forms  of  calculi  which  are  at  all  of  common 
occurrence,  and  which  are,  therefore,  likely  to  demand  analysis.  These 
are  uric  <ici<l  <ru<l  its  compounds,  oxalate  of  lime,  and  the  mixed  phosphates. 
Calculi  of  xanthine  and  c>/s!in<'  are  found,  though  very  rarely. 

1.  Uric  aoid  calculi  arc  the  most  common.  They  are  either  red  or 
some  shade  of  red,  and  usually  smooth,  but  may  be  tubcrculated.  They 
leave  a  mere  trace  of  residue  after  iguitiou. 

2.  Oxalate  of  lime  calculi  are  frequently  met  with.  They  are  generally 
of  a  dark  brown  or  dark  gray  color,  and  from  their  frequently  tubcrcu- 
lated surface  have  been  called  mulberry  calculi.  They  may,  however, 
also  be  smooth.  Considerable  residue  remains  after  ignition.  The  calculus 
is  soluble  in  mineral  acids  without  effervescence. 

3.  Calculi  of  the  mixed  phosphates  or  fusible  calculi  are  composed  of 
the  phosphate  of  lime  and  of  the  triple  phosphate  of  ammonia  aud  mag- 
nesia. They  form  the  external  layer  of  many  calculi  of  different  compo- 
sition, and  may  form  entire  calculi,  but  very  seldom  form  the  nuclei  of 
other  calculi.  They  are  white,  exceedingly  brittle,  fuse  in  the  blowpipe 
flame,  and  are  soluble  in  acids,  but  insoluble  in  alkalies. 

Few  calculi  of  large  size  are  of  the  same  composition  throughout. 
Oxalate  of  lime  is  the  most  frequent  nucleus  ;  uric  acid  may  also  serve 
as  a  nucleus,  but  phosphates,  as  stated,  almost  never.  Small  collections 
of  organic  matter,  as  blood-clots,  frequently  form  nuclei,  and  may  often 
be  recognized  by  the  odor  of  ammonia  on  ignition.  It  is  not  uncommon 
to  find  calculi  made  up  of  concentric  layers  of  different  composition. 

TO  DETERMINE   THE   COMPOSITION  OF  CALCULI.* 

Heat  a  portion  of  the  powdered  calculus  to  redness  upon  platinum 
foil.     Note  whether  there  is  a  residue. 

A.  There  is  a  fixed  residue.  To  a  portion  of  the  original  powder  apply 
the  murexid  test.  (This  is  as  follows :  Dissolve  a  small  portion  of  the 
powder  in  a  drop  of  nitric  acid  on  a  porcelain  plate,  then  carefully 
evaporate  over  a  spirit  lamp.     When  dry  add  a  drop  or  two  of  liquor 

*  The  processes  here  given  are  taken,  with  slight  alterations,  from  Tlmdi churn's  work 
on  the  Pathology  of  the  Urine. 


DISEASES    OF   THE   UEINAItY   SYSTEM.  217 

ammonias,  when,  if  uric  acid  is  present,  a  beautiful  purple  color  will 
appear  where  the  ammonia  spreads). 

I.  A  purple  color  results  ;    uric,  acid  is  present.     Observe  whether 
a  portion  of  the  calculus  melts  on  being  heated. 

a.  It  melts  and  communicates — 

1.  A  strong  yellow  color  to  the  flame  of  a  spirit  lamp  : 
sodium  urate. 

2.  A  violet  color  to  the  flame ;  potassium  urate. 

b.  It  does  not  melt.  Dissolve  the  residue  after  ignition  in  a 
little  dilute  HC1,  add  ammonia  until  alkaline,  and  then 
ammonium  carbonate  solution. 

1.  A  white  precipitate  falls  ;  calcium  urate. 

2.  No  precipitate.  Add  some  hydric  sodic  phosphate 
solution;  a  white  crystalline  precipitate  falls;  magnesium 
urate. 

II.  No  purple  color  results.     Observe  whether  a  portion  of  the 
calculus  melts  on  being  heated  strongly. 

a.  It  melts  (fusible  calculus).  Treat  the  residue  with  acetic 
acid  ;  it  dissolves.  Add  to  the  solution  ammonia  in  excess  ; 
a  white  crystalline  precipitate  falls ;  ammonio-magnesium 
phosphate.  In  case  the  melted  residue  is  insoluble  in  acetic 
acid,  treat  with  HC1 ;  it  dissolves.  Add  to  the  solution 
ammonia  ;  a  white  precipitate  indicates  calcium  phosphate. 

b.  It  does  not  melt.  Moisten  the  residue  with  water,  and  test 
its  reaction  with  litmus  paper ;  it  is  not  alkaline.  Treat 
with  HC1 ;  it  dissolves  without  effervescence.  Add  to  the 
solution  ammonia  in  excess ;  white  precipitate ;  calcium 
phosjyhate.  Treat  the  calculus  with  acetic  acid  ;  it  does  not 
dissolve.  Treat  the  residue  after  heating  with  acetic  acid  ; 
it  dissolves  with  effervescence  ;  calcium  oxalate.  Treat  the 
original  calculus  with  acetic  acid  ;  it  dissolves  with  efferves- 
cence ;  calcium  carbonate. 

B.  There  is  no  fixed  residue.     Apply  the  niurexid  test  (p.  216). 
I.  A  purple  color  is  developed. 

a.  Mix  a  portion  of  the  powdered  calculus  with  a  little  lime, 
and  moisten  with  a  little  water ;  ammonia  is  evolved,  and  a 


_  1  B  DIFFERENTIAL   DIAGNOSIS. 

red  litmus  paper  suspended  over  the  mass  is  turned  blue; 
ammonium  urate. 
b.  Xo  ammonia  ;   uric  acid. 
II.  No  purple  color. 

a.  But  the  nitric  acid  solution  turns  yellow  as  it  is  evaporated, 
and  leaves  a  residue  insoluble  in  potassium  carbonate ; 
xanthine. 

b.  The  nitric  acid  solution  turns  dark  brown,  and  leaves  a 
residue  soluble  in  ammonia  ;  cystine. 


INDEX. 


Abdominal  phthisis,  195. 
Abscess,  cerebral,  85. 
Acidity  of  the  stomach,  186. 
Acute  yellow  atrophy  of  liver,  203. 
Albrecht,  R. ,  relapsing  fever,  52. 
Albuminoid  liver,  202. 

kidney,  211. 
Amyloid  liver,  202. 

kidney,  211,  212. 
Amyotrophic  paralysis,  101. 
Anaemic  murmurs,  173. 
Anaemia,  pernicious,  66  ;  cerebral,  75 
Angina  pectoris,  174. 
Anstie,  F.  E.,  neuralgia,  117;  test  for 

hoi,  76. 
Aortic  diseases,  175. 
Apoplexy,  75-77. 

meningeal,  of  the  cord,  95 

spinal,  96. 

pulmonary,  161. 
Appetite,  185. 
Arthritic  dyscrasia,  the,  54. 
Arthritis,  rheumatica  deformans,  66. 
Ascarides,  206. 
Asthma,  162. 
Atrophy  of  the  liver,  203. 

Barlow,  Thos.,  hysteria,  115. 
Bennett,  J.  H.,  142. 
Bile  in  the  urine,  215. 
Billroth,  T.,  dyscrasia,  54. 
Blood,  diseases  of,  54. 

in  malarial  fever,  42. 

relapsing  fever,  52. 

pernicious  anaemia,  67. 

leukaemia,  67. 
Blood-cell  counting,  67. 
Bocher,  Dr. ,  rheumatic  gout,  66. 
Boxichut,  ophthalmoscope,  80. 
Boulimia,  185. 
Bowels,  obstruction  of,  196. 
Brain  tumors,  85. 
Bramwell,  B.,  anaemia,  67. 
Bri£>ht' s  disease,  208. 
Broca,  Dr.,  86. 
Bronchitis,  148,  152. 


alco- 


Browne,  L.,  diseases  of  the  larynx,  135. 
Brown-S^quaiu),  on  paraplegia,  105. 
Bullard,  Gr.  B.,  34. 

Calculi,  biliary,  201. 
urinary,  216. 
Cancer  of  the  lung,  165. 
liver,  203. 
Capillary  bronchitis,  155. 
Cardiac  dilatation,  180. 

hypertrophy,  181. 
degeneration,  170. 
Catarrhal  phthisis,  143. 
Cerebral  abscess,  85. 
anaemia,  75. 
apoplexy,  75-77. 
congestion,  75. 
cortex,  lesions  of,  86. 
disorders,  chronic,  84. 
exhaustion,  75. 

hemorrhage,  thrombosis  and  em- 
bolism compared,  75,  77. 
inflammations,  78. 
meningitis,  78. 
sclerosis,  85. 

sinuses,  thrombosis  of,  85. 
Cerebro- spinal  affections,  98. 
fever,  43. 
sclerosis,  104. 
Cirrhosis  of  liver,  204. 

kidney,  211. 
Clubbing  of  fingers,  172. 
Charcot,  Prof.,  cerebro-spinal  affections, 


Cheyne-Stokes  respiration,  182. 
Colitis,  197. 

Concussion  of  brain,  75. 
Congestive  chills,  39. 

or   pernicious   malarial    fever, 
39,  44. 
Consumption,  galloping,  150. 
Continued  fever,  33. 
Copland,  Dr.,  32. 
Cord,  diseases  of  the.  91,  93. 

congestion  of  the,  95,  96. 
Croup,  130. 

219 


lNl'KX. 


m;ium.  D.  D..  zymotic  <lisease,  68. 
CuKTMAN,    C.   <»..    color    of    the    malarial 
tongue,  11. 

Da  Costa,  J.  M.,  on  exanthemata,  21. 
typhoid  fever.  28. 
cerebro-spinal  fever,  46. 
bear!  disease,  182. 
Dartrooa  dyscrasia,  the,  54. 
Day,  Wit.  'II..  headaches,  82. 
Degeneration,  tatty,  of  heart,  181. 
Dei  m  mi  t>.  P.,  scrofula,  57. 
Diabetes,  212. 
Diagnosis  between 

[Inflammatory  and  essential  fevers,  20. 

Essential  and  eruptive  fevers,  21. 

Rotheln,  scarlel  fever,  measles,  and 
smallpox,  24. 

Typhoid  and  typhus,  28. 

Typhoid  ami  malarial,  34. 

Typhoid  and  typho-malarial,  37. 

Typhoid  state  and  typhoid  fever,  38. 

Cerebro-spinal  fever  and  congestive  per- 
nicious malarial  fever,  41. 

Epidemic  and  sporadic  cerebro-spinal 
meningitis,  45. 

Epidemic  cerebro-spinal  vs.  typhus 
fever,  46. 

Yellow  and  bilious  remittent,  51. 

Relapsing  and  typhoid,  53. 

Scrofulosis,  tuberculosis,  and  inherited 
syphilis.  60. 

Diseases  bkely  to  be  confounded  with 
acute  rheumatism.  61. 

Diseases  likely  to  be  confounded  with 
chronic  rheumatism,  62. 

Gout  and  rheumatism,  65. 

Cerebral  congestion  and  ansemia,  75. 

Cerebral  apoplexy  vs.  drunkenness, 
uraemia,  etc.,  75. 

Acute  cerebral  inflammations,  78. 

Cerebral  hemorrhage,  thrombosis,  and 
embolism,  77. 

Forms  of  headache,  83. 

Eypertrophy  and  hydrocephalus,  84. 

Intelligence,  deficient,  and  cerebral  scle- 
rosis, 85. 

Forms  of  paralysis,  89. 

Spinal  paralysis.  91. 

Spinal  diseases,  93. 

Acute  spinal  diseases,  96. 

Myelitis,  meningitis,  and  spinal  conges- 
tion. 96, 

Locomotor-ataxia,  multilocular  sclerosis. 
disseminated  syphilosis,  general  pa- 
ralysis, 98. 


Cerebro-spinal    sclerosis,    paralysis   agi- 

tans,  and  locomotor-ataxia.   KM. 
Paraplegia    from    reflex   irritation   and 

from  myelitis.   105. 
General  paralysis  and  locomotor-ataxia. 

112. 
True    and    svphilitie    general    paralysis, 

113. 
Spinal  irritation  and  spinal  weakness,  114 
Epilepsy  and  hystero-epilepsy,  116. 
Neuralgia  and  myalgia,  118. 
Cerebral  abscess  and  neuralgia,  119. 
Insanity,  forms  of,  120. 
Spasmodic  and  inflammatory  croup,  130. 

.Membranous  croup  and  diphtheria,  181. 

Tonsillitis,  catarrhal  and  parenchyma- 
tous, 132. 

Diseases  of  respiratory  system,  142. 

Chronic  catarrhal  pneumonia  (inflam- 
matory phthisis),  interstitial  pneumo- 
nia (fibroid  phthisis),  and  tubercular 
phthisis,  144,  145. 

Incipient  phthisis  and  bronchitis,  148. 

Bronchitis,  acute  and  chronic,  153,  154. 

Capillary  bronchitis  and  pneumonia, 
155. 

Pneumonia  and  pleurisy,  155,  158. 

Pleurisy  and  hydrotliorax,  157. 

Pulmonary  apoplexy  and  pneumonia, 
161. 

Pneumothorax  and  hydro-pneumotlm- 
rax,  164. 

Emplvyscnia,  vesicular  and  interlobular, 
164. 

Pulmonary  cancer  and  phthisis,  166. 
and  pleurisy,  166. 
and  syphilis,  166. 

Heart  diseases,  170. 

Aortic  obstruction  and  incompetency. 
175. 

Pulmonary  obstruction  and  tricuspid  re- 
gurgitation, 178. 

Mitral  obstruction  and  mitral  incompe- 
tency. 176. 

Endocardial  and  exocardial  sounds,  180. 

Dilated  heart  and  pericardial  effusions, 
180. 

Hypertrophy  and  dilatation  of  heart, 
181. 

Acidity  of  stomach  from  fermentation 
vs.  hypersecretion,  186. 

Gastric  and  cerebral  vomiting,  189,  190. 

Atonic  dyspepsia,  chronic  gastritis,  gas- 
tric ulcer  and  gastric  cancer,  193. 
Indigestion  and  dyspepsia,  194. 

Enteritis  and  dysentery,  197. 


INDEX. 


■l->\ 


Obstructive  and  symptomatic  jaundice, 

200. 
Diabetes  mellitus  and  glycosuria,  213. 
Forms  of  Bright' s  disease,  210. 
Diabetes  insipidus  and  hydruria,  215. 

Diagnosis  of  incipient  phthisis,  145. 

Diarrhoea,  197. 

Dilatation  of  heart,  181. 

Diphtheria,  130. 

Dobell,  H.,  pain  at  the  heart,  173. 

Donnet,  J.  J.  L.,  50. 

Dowell.G.,  yellow  fever,  49. 

Dowse,  Dr.,  cerebro-spinal  meningitis,  45. 

Drachmann,  Dr.,  on  rheumatic  gout,  66. 

Drake,  D.,  on  remitto-typhus,  36. 

malignant  remittent,  40. 

Drunkenness,  75. 

Duchenne,  Dr.,   pseudo-hypertropliic  pa- 
ralysis, 108. 

Duggan,    J.,   scarlatina,   early    diagnosis 
of,  22. 

Dyscrasise,  the,  54. 

Dysentery,  197. 

Dyspepsia,  185,  191. 

Eichhorst,  Dr.,  pernicious  anaemia,  66. 

Embolism,  cerebral,  75-77. 

Emphysema,  164. 

Empyema,  160. 

Endocardial  sounds,  169,  170,  180. 

Enteritis,  197. 

Entero-miasmatic  fever,  34. 

Epidemic  meningitis,  43. 

Epilepsy,  75,  116. 

Erb,  spinal  disorders,  103. 

Eructation,  188. 

Eruptive  fevers,  21. 

Essential  fever,  19. 

paralysis,  101. 
Exanthemata,  the,  21. 
Exocardial  sounds,  180. 

Fatty  degeneration  of  heart,  181. 

of  liver,  203. 

of  kidney,  210. 
Febrile  state,  the,  15. 
Fingers,  clubbing  of,  172. 
Flatulence,  188. 

Flint,  A.,  cerebral  disorders,  77. 
Fox,  vomiting,  190. 

Gallstones,  201. 

Garrod,  A.  B.,  on  gout,  65. 

Gastric  fever,  33. 

ulcer,  191. 

cancer,  191. 
Gee,  meningitis,  79. 


G-ELPKE,  Dr.,  71. 

General  disease   defined,  13. 

paralysis  of  fch<  109. 

symptoms  of  nervous  disease,  '■•■ 
Germ  theory,  68. 
Glycosuria,  212. 
Gmelin's  test,  215. 
Gout,  65. 

rheumatic,  66. 
Gowers,  Dr.,  blood-cell  counting.  66. 

diseases  of  spinal  cord.  09, 
107. 
Griffin,  W.  and  D.,  114. 

Habershon,  S.  O.,  61. 
Hall,  J.  C,  42. 

Hamilton,    A.    M.,     on    cerebro-spinal 
fever.  44. 
on  tubercular  meningitis,  48. 
Hardy,  Dr.,  rheumatic  diathesis.  55. 
Hatden,  cerebro-spinal  meningitis,  45. 

heart  disease,  182. 
Headache,  82. 
Heart  disease,  170. 
pain  in,  173. 
Hemorrhage,  cerebral,  75-77. 
Hemorrhagic  malarial  fever,  40. 
Hensch,  paralysis,  90. 
Hepatic  disease,  202. 

abscess,  203,  204. 
Herpes  zoster,  62. 

Hewitt,    P.,    symptoms  of   arthritic  dia- 
thesis, 55. 
Hume,  E.  M.,  typhoid  and  malarial  fevers, 

34. 
Hutchinson,  congenital  syphilis,  88. 

gout  vs.  rheumatism.  54. 
Hydruria,  215. 
Hydrocephalus,  84. 
Hydrothorax,  157. 
Hydatids  in  the  liver,  203,  206. 
Hyperplasia  of  the  liver,  z02. 
Hypertrophy  of  the  brain,  84. 
heart,  181. 
Hysteria,  115. 
Hysterical  paralysis,  109. 
Hystero-epilepsy,  116. 

Impotence,  a  symptom  of  diabetes.  214. 
Indigestion,  194. 
Inflammatory  fever,  19. 

diarrhoea,  197. 
Inman,  myalgia,  63. 
Intelligence,  defective,  85. 
Insanity,  120. 
Intercostal  neuralgia,  118. 


90.9. 


l.NDKX. 


Intermittent  fever,  38. 
Internal  parasites,  205. 
Intussusception,  190. 

Jaundice,  200. 

Jurgexskx,  Dr.,  typhoid  fever,  20. 

Kki.su.  A.,  malarial  blood,  42. 
Kidney,  diseases  of,  210. 

Lateral  sclerosis,  99. 

Labrabee,     A.,  prodromata    of    typhoid 
fever;  29. 

Laryngitis,  135. 

Larynx,  diseases  of,  124. 

Lead  poisoning,  paralysis  from,  108. 

Lepto-meningitis,  78. 

Leukaemia,  66. 

Liver,  diseases  of,  198. 

Local  diseases  defined,  13. 

symptoms  of  essential  fevers,  20. 
Localization  of  brain  disease,  86, 

and  spinal  cord,  87,  93. 
Locomotor-ataxia,  63,  100,  104. 
Love,  Wm.  A.,  tongue  of  malaria,  41. 
Lumbrici,  206. 
Lungs,  diseases  of  the,  132. 

cancer  of,  165. 

Mac  Ewex,  test  for  alcoholism,  70. 

Mac  Swixey,  Dr.,  syphilitic  phthisis,  152. 

Malarial  fever,  34,  38,  48. 

toxaemia,  41. 
Malignant  remittent,  39. 
Mania.  120. 
Measles,  24. 
Melancholia,  120. 
Meningeal  apoplexy,  95. 
Meningitis,  cerebral,  78. 

cerebro-spinal  or  epidemic,  43. 
chronic,  85. 
sporadic  or  basic,  43. 
acute  tubercular,  granular,  48. 
Methods  of  physical  examinations,  136. 
Miliary  tuberculosis,  130. 
Milk  leg,  02. 
Mitral  diseases,  170. 
Monti,    Alois,    condition    of    throat    in 

scarlatina,  23. 
Moss,  E.  L.,  blood  of  malaria,  43. 
Multilocular  sclerosis,  104. 
Myalgia,  03,  118. 
Myelitis,  acute  primary,  96. 

chronic,  90-98. 

Narcotic  poisoning,  96. 
Nephritis,  acute  and  chronic,  210. 


Nervous  disorders,  73. 
Neuralgia.  94,  117. 

compared   with   chronic    rheu- 
matism, 62. 

with  myalgia,  118. 
Neurasthenia,  spinalis,  11">. 
Xir.MKvr.u.  F.  Vox,  on  gastric  fever,  88. 

Obstruction  of  the  bowels,  196. 
( Ophthalmoscope,  80. 

Osler,    Dr.,    initial    rashes   of    eruptive 
fevers,  23. 

Paget,  Sir. J.,  symptoms  of  arthritic  dia- 
thesis, 56. 
Pain  at  the  heart,  173. 
in  the  stomach,  187. 
in  the  liver,  199. 
Paralysis  agitans,  104. 
general,  109. 
the  forms  of,  89,  93. 
pseudo-hypertrophic,  107. 
from  lead  poisoning,  108. 
Paraplegia,  105. 
Parasites,  internal,  205. 
Parenchymatous  renal  degeneration,  211. 
1'kxtimalli,  syphilitic  phthisis,  152. 
Pericarditis,  178. 
Pericarditis  with  effusion,  180. 
Perichondritis,  128. 
Pernicious  anaemia,  66. 
Phthisis,  143,  149. 

syphilitic,  152. 
abdominal,  195. 
Physical  diagnosis,  132* 
Pleurisy,  157,  160. 
Pleurodynia,  118. 
Pneumonia,  155-100. 
Pneumothorax,  162. 
Pneumo-hydro-thorax,  163. 
Poisoning,  narcotic,  76;  uraemic,  75. 
Progressive   locomotor    ataxia,   see   scle- 
rosis, posterior  spinal. 
Pseudo-hypertrophic  paralysis,  107. 
Pulmonary  apoplexy,  161. 
embolism,  161. 
cancer,  165, 
obstruction,  158. 
thrombosis,  161. 
Pulse  in  leading  fevers,  17. 
Pyaemia,  62. 

Relapsing  fever,  52, 
Remittent  fever,  39, 
Rem  itto- typhus  lever,  34. 
Renal  disease,  64,  210. 


INDKX. 


223 


Retinitis  albuminurica,  209. 

Reynolds,  R.,  symptoms  of  rheumic  dia- 
thesis, 55. 

Rheumatic  gout,  66. 

Rheumatism,  62  ;  compared  with  gout,  65. 
chronic,  62. 

Rheumatoid  arthritis,  66. 

Rheumic  dyscrasia,  the,  54. 

Richardson,  J.  G.,  leukaemia,  67. 

Ringer,  S.,  16,  18. 

Romberg,  cerebral  vomiting,  189. 

Rosenthal,  Dr.,  76. 

Rotch,  T.  M.,  sign  of  pericardial  effu- 
sion, 181. 

Rubeola,  25. 

Scarlet  fever,  22. 
Sclerosis,  85. 

posterior  spinal,  63,  100,  104. 
multilocular,  104. 
of  antero-lateral    column,     99, 
104. 
Scrofulous  dyscrasia,  the,  56. 
Segdin,  E.  C.,  lesions  of  cortex,  87. 
Shingles,  62. 
Skin  in  fever,  187. 

disease  of  diathetic  origin,  55. 
Smallpox,  22. 
Softening  of  brain,  85. 
Southey,  R. ,  tubercular  meningitis,  48. 
Spinal  apoplexy,  96. 

congestion,  95,  96. 
diseases,  acute,  91,  93  ;  chronic,  97. 
tumors,  97. 
irritation,  114. 
meningitis,  96. 
Spirillium  in  relapsing  fever,  52. 
Spotted  fever,  43. 
Stille,  A.,  epidemic  cerebro-spinal  fever 

and  typhus,  46. 
Stokes,  Wm.,  on  fever,  20. 
Strumous  dyscrasia,  the,  56. 
Sunstroke,  75. 
Symptomatic  fever,  19. 
Synovitis,  acute,  62. 
Syphilis,  osteocopic  pains  of,  63. 
Syphilitic  dyscrasia,  the,  58. 
laryngitis,  126. 
phthisis,  152. 
teeth,  58. 

general  paralysis,  109. 
Syphilosis,  disseminated,  of  the  cord,  113. 

Tache  c6r6brale,  the,  49. 


Tape  worm,  206. 

Teeth,  rheumatic  markings  on,  64. 

syphilitic,  68. 
Temperal are  in  fever,  17. 

rules  for  taking,  L6. 
of  leading    febrile  <\\  ■  -.<  •    . 
17. 
Tendon-reflex,  102. 
Thread  worms,  206. 
Throat  in  eruptive  fevers,  21. 
Thrombosis,  cerebral,  75,  77,  85. 
Tongue  in  digestive  disorders,  184. 
in  fever,  16. 

in  malarious  disease,  41. 
Tonsillitis,  132. 
Tremors,  97. 

Tricuspid  regurgitation,  178. 
Trichinosis,  206. 

Trousseau,  A.,  scarlatinal  sore  throat,  52. 
Tubercular  dyscrasia,  the,  59. 
laryngitis,  127. 
peritonitis,  195. 
meningitis,  78. 
Tuberculosis  of  lung,  143. 
Typhlitis,  34. 
Typhoid  fever,  28. 

types  of,  33. 
state,  the,  37. 
Typho-malarial  fever,  34. 
Typhus  fever,  29. 

Urtemia,  75. 
Urinary  calculi,  216. 

organs,  diseases  of,  208. 
Urine  in  fever,  18. 

Variola,  21. 
Vertigo,  188. 
Vomit,  black,  49. 
Vomiting,  189. 

Warter,  J.  S.,  on  fever,  17. 

Waters,  A.  T.  H.,   tuberculous  dyscrasia, 

59. 
Wegscheider,  H.,  16. 
Westphal,  Dr. ,  tendon  reflex,  102. 
Whittle,  W.,  uraemia,  76. 
Wood,  H.  C.  Jr.,  spinal  disease,  91. 
Woodward,    J.  J.,   typho-malarial  fever, 

36. 
Worms,  206. 
Wunderlich,  temperature  in  fever,  17. 

Yellow  fever,  49. 


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and  Obstetrics  : — 

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Medical  News,  .March,  1880. 

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tin-  -tudent."—  The  Therapeutic  Gazette,  March,  1880. 

"We  consider  it  superior  to  either  one  of  tin-  other  volumes."—  Cincinnati  Medical  News. 
March,  1880. 

"We  recommend  it  as  tilliii-  :.  general  want."— Atlanta  Medical  and  Surgical  Journal, 
February,  I 

4 


A  BIOGRAPHICAL  DICTIONARY 

OF 

CONTEMPORARY  AMERICAN  PHYSICIANS 

AND 

STJROBOITS. 


Edited    by    "WJVE.    H.    ATKINSON,    M!.  D., 
Permanent  Secretary  of  the  American  Medical  Association,  and  of  the  Pennsylvania  State  Medi- 
cal Society  ;  LecHirer  on  Diseases  of  Children  at  the  Jefferson  Medical  College,  etc. 


One  Volume,  Royal  Ociavo,  Double  Columns,  780  pp.,  on  Fine,  Tinled  Paper. 

JB®"  REDUCED    PRICE.°®a 
With  52  Full-page  Steel  Portraits,  Half  Leather,     .     $7.50 
Same  without  the  portraits, only   4.00 


This  really  monumental  work,  the  fruit  of  enormous  labor  and 
outlay,  contains  the  biographical  sketches  of  more  than  twenty- eight 
hundred  contemporary  regular  physicians  of  the  United  States,  prepared 
from  materials  in  most  instances  furnished  by  themselves,  and  hence 
entirely  trustworthy.  Indexes  of  names  and  places  are  appended.  The 
effort  has  been  made  to  embrace  all  who  have  visibly  contributed  to  the 
advancement  of  medical  science  in  all  parts  of  the  Union,  and  the  volume 
presents  a  mass  of  most  valuable  historical,  biographical  and  scientific 
material. 

IN    PRESS.      READY    MARCH    1st,    1881. 


THE  PRINCIPLES  AND  METHODS 

OF 

THERAPEUTICS. 

BY  ALPHONSE  GUBLER,  M.D., 
Professor  of  Therapeutics  in  the  Faculty  of  Medicine  of  Paris,  etc. 

TRANSLATED  FROM  THE  FRENCH.  ONE  VOL.,  8vo. 

Gtjbler  may  be  said  to  have  been  the  most  distinguished  exponent 
of  scientific  therapeutics — in  the  best  sense  of  the  term — of  this  genera- 
tion. Following  Trousseau  in  the  professional  chair,  aud  a  pupil  of  that 
great  teacher,  he  toek  a  long  step  in  advance  of  his  master,  and  may  be 
said  to  have  developed  the  only  method  of  therapeutics  which  reconciles 
the  empirical  and  clinical  art  of  medicine  with  the  demands  of  exact 
and  logical  science.  His  labors  created  a  new  epoch  in  professional 
practice  in  France,  and  in  all  other  countries  where  they  have  become 
known  have  made  a  profound  impression  on  the  professional  mind. 

5 


DIFFERENTIAL  DIAGNOSIS: 

A    MANUAL   OF   THE    COMPARATIVE   SEMEIOLOGY   OF   THE 

MORE    IMPORTANT   DISEASES. 

By  DE  HAVILLAND  HALL,  M.D., 

Assistant  Physician  to  the  Westminster  Hospital,  London. 

Second  American  Edition,  with  Extensive  Additions. 
EDITED  BY  FRANK  WOODBURY.  M.D. 

One  Volume,  Svn.  pp.  -2'2:\.    Printed  on  handsome  tinted  paper;  bonnd  in  Knglish  pebbled 
cloth,  with  beveled  boards.    Price  $2.00. 


Dr.  Hall's  work  has  received  the  highest  encomiums  from  the 
English  medical  press,  for  its  lucid  arrangement,  completeness  and  accu- 
racy. He  himself  is  known  in  London  as  a  practitioner  of  great  skill, 
and  an  unusually  successful  medical  teacher. 

Most  of  the  diseases  which  may  he  confounded  are  presented  in 
comparative  tables,  setting  forth  their  distinctive  characteristics  in  the 
clearest  possible  light,  and  thus  greatly  facilitating  their  prompt  diag- 
nosis. 


THE  DISEASES  OF  LIVE  STOCK, 

INCLUDING  HORSES,  CATTLE,  SHEEP  AND  SWINE. 

Containing  a  description  of  all  the  usual  diseases  to  winch  these  animals  are 

liable,  and  the  most  successful  treatment  of  American, 

English  and  European  Veterinarians. 

13y    LLOYX>    V.   TELLOR,    M. r>. 

1  vol.  8vo.  pp.  474.    Price.  Cloth,  $2.50. 


This  work  is  divided  into  four  parts,  as  follows  :  I.  General  Princi- 
ples of  Veterinary  Medicine.  II.  Diseases  of  the  Horse.  III.  Diseases 
of  Cattle,  Sheep  and  Swine.    IV.  Hygiene  and  Medicines. 

The  author  of  this  work  is  a  regular  physician,  whose  practice  in  the 
country  has  led  him  to  study  the  diseases  of  domestic  animals,  and  we 
can  point  to  it  as  the  first  and  only  hook,  by  an  American  physician, 
which  describes,  with  scientific  accuracy,  and  yet  in  plain  language, 
these  common  and  important  maladies. 

From  WILLIAM    A.   HAMMOND,  M.D.,  of  New   York  City,  Late  Surgeon  General,   U.   S. 

Army. 

"I  have  gone  through  Dr.  Tellor's  book  very  carefully,  and  regard  it  as  admirably  ndapted  for 
the  use  of  those  who  are  obliged  to  treat  their  own  animals.  It  is  eminently  practical  and  full  of 
common  sense." 

6 


LESSONS  IN  GYNECOLOGY. 

BY  ¥M.  GOODELL,  A.M.,  M.D., 

Professor  of  Clinical  Gynaecology  in  the  University  of  Pennsylvania. 

SECOND   EDITION. 

THOROUGHLY  REVISED  AND  CONSIDERABLY  ENLARGED,  WITH 

NUMEROUS  ILLUSTRATIONS. 

One  Volume,  Svo.    Price,  Cloth,  $4.00;  Sheep,  $4.50. 


The  Second  Edition  of  this  able  work  was  demanded  within  three 
months  from  the  publication  of  the  first.  The  author  has,  however, 
taken  the  time  to  give  it  a  very  careful  revision,  and  has  added  a  large 
amount  of  new  and  unpublished  material. 

"This  volume  is  one  which  must  take  a  high  rank  among  works  upon  the  subject  of  which  it 
treats.  It  presents  striking  and  rare  merits,  showing  close  observation,  accurate  description  and 
sound  reasoning." — Medical  Times  and  Gazette,  London,  November,  1880. 

"We  commend  this  book  to  those  who  are,  or  who  wish  to  become,  gynascologists.  Its  great 
value  is  its  practicalness.  Little  points  of  detail  teem  up  on  almost  every  page,  showing  that  it  is 
the  work  of  a  man  who  has  often  done  what  he  wishes  his  readers  to  do. —  Glasgow  Medical  Jour- 
nal, November,  1880. 


COMMON  MIND-TROUBLES, 

AND 

THE  SECRET  OF  A  CLEAR  HEAD. 

By  J.  MORTIMER-GRANVILLE,  M.D.,  F.R.C.S.,  LONDON,  etc. 

One  Vol.,  Crown  8vo,  Cloth,  pp.  185.     Price  $1.00. 


Reprinted   from  the  Eleventh,  thousand,  of  the  London  Edition,  with 
additions  by  the  American  Editor. 


CONTEXTS. 

PART  I.  Mental  Failings — Defects  of  Memory — Confusions  of 
Thought — Sleeplessness  from  Thought — Hesitations  in  Speech — Low 
Spirits— Good  and  Bad  Tempers — Mental  Languor  and  Listlessness — 
Morbid  Fears  — "  Creatures  of  Circumstance." 

PART  II.  Temperature — Habit  —  Time — Pleasure— Self-Import- 
ance— Consistency — Simplicity — The  Secret  of  a  Clear  Head. 

7 


Atkinson.     Hints  on  the  Obstetric  Procedure.     Svo.     Cloth,  SI. 00. 

"The  nmnv  valuable  points  cited,  the  practical  manner  in  which  they  are  stated,  together  with 
Die  Bound  \  i>'«  b  of  practice  enunciated,  make  this  little  monograph  truly  valuable." — The  Southern 
Practitioner,  January,  1879. 

••  It  is  the  gist  of  the  obstetric  ait  in  convenient  form,  and  will  Berve  to  refresh  the  practitioner's 
mind  in  any  case  pertaining  thereto." — Maryland  Medical  Journal,  June,  1879. 

Bernard  and  Huette.  Operative  Surgery  and  Surgical  Anatomy. 
Magnificently  illustrated  on  steel.  Colored  plates.  New  edition 
in  preparation. 

Dowell.  Yellow  Fever  and  Malarial  Diseases.  With  a  Map.  Cloth, 
$2.00. 

Dobell.  On  Coughs,  Consumption,  and  Diet  in  Disease,  pp.  222.  Cloth, 
$2.00. 

As  an  authority  on  the  above  Biibjects  Dr.  Dobell  ranks  second  to  none  in  Great  Britain.     His 

. ■\|"-rii-ii(-''  has  been  immense,  and  the  peculiarly  practical  tone  of  his  mind  renders  his  writings 
unusually  instructive  to  the  practicing  physician. 

Hargis.  Yellow  Fever,  its  Ship  Origin  and  Prevention.  Svo.  (Just 
issued).     Cloth,  51.00. 

Landolt.  Manual  of  Examination  of  the  Eyes.  Illustrated,  pp.  307. 
Numerous  illustrations  and  Chart,  $3.00. 

"This  hook  is  a  most  admirable  and  complete  exposl  of  our  means  and  methods  of  making  a 
thorough  scientific  examination  of  the  human  eye.  Written  in  the  attractive,  easy  style  of  lectures, 
unencumbered  by  unnecessary  mathematical  formulae,  printed  on  heavy  paper  and  in  large  and 
char  type,  translated  with  care  and  skill  into  fluent  English,  this  book  will  contribute  largely  toward 
awakening  greater  interest  for  ophthalmology 'among  the  reading  members  of  our  profession." — 
Chicago  Medical  Journal  and  Examiner,  August,  1870. 

Seiler.  Compendium  of  Microscopical  Technology,  pp.  Svo.  (Just 
issued.)    Price,  $1.00. 

Dr.  Carl  Seiler,  of  Philadelphia,  gives  in  this  admirably  lucid  opitome  of  microscopy  just  that 
information  which  the  student  and  physician  requires  to  work  the  microscope  advantageously.  It  is 
well  illustrated  and  contains  a  comparative  table  of  neoplasms  of  great  value. 

In  Preparation.  Ready  about  A-pril  1,  1881. 

HYDROPHOBIA, 

.A.    Monograph,   for    the    Profession   and   the    Public. 

By  H.  R.  BIGEL0W,  M.D. 


This  treatise,  the  outcome  of  several  years'  study  of  this  terrible 
complaint,  will  contain  the  latest  investigations  into  its  pathology, 
causes,  communicability,  prognosis,  prophylaxis  and  treatment. 

8 


COLUMBIA   UNIVERSITY 

This  bqo.k  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 


DATE  BORROWED 


C26'63B>MBO 


RC71 
Hall 


H14 

1881 


" 


H 


